A nurse is assessing a newborn who has Trisomy 21 (Down's Syndrome). Which of the following are common characteristics? (Select all that apply.)

Large ears

Protruding tongue

Transverse palmar creases

Muscular hypertonicity

Low birth weight

Answer and Explanation

Correct Answer : B,C

B. A protruding tongue, often due to a small mouth and poor muscle tone (hypotonia), is a common feature of Down syndrome. This tongue appearance can contribute to difficulties with feeding and speech development.

C. Instead of a single palmar crease (known as a simian crease), individuals with Down syndrome often have transverse palmar creases. This occurs in about 45-50% of cases and is considered a characteristic feature.

A. While large ears are not typically listed as a common feature, individuals with Down's Syndrome may have unusually shaped or small ears.

D. Hypertonicity refers to increased muscle tone or stiffness. In Down syndrome, however, hypotonia (reduced muscle tone) is more common, especially in infancy. Therefore, muscular hypertonicity is not typically associated with Down syndrome.

E While low birth weight can occur in some infants with Down syndrome, it is not a universal characteristic. In fact, some infants with Down syndrome may be born at average or even slightly higher birth weights.

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Correct Answer is C

Explanation

C. Station 0 means that the presenting part of the fetus (usually the head) is at the level of the maternal ischial spines. At this point, the fetus is engaged in the pelvis, but has not descended further into the birth canal (below the ischial spines).

A. The position of the presenting part (station) is not directly related to whether the posterior fontanel (back of the fetal head) is palpable. Palpability of the fontanelles is more related to the position of the fetal head and its orientation in relation to the mother's pelvis.

B. Station does not describe the specific position of the fetal head (e.g., occiput posterior). Station focuses on how far the presenting part is relative to the ischial spines.

D. This statement describes full dilation (10 cm) rather than station. Full dilation occurs when the widest part of the fetal head (largest diameter) passes through the pelvic outlet during the second stage of labor.

A. Prepare the client for emergency cesarean section. B. Recheck the client's temperature in 4 hr. C. Assess the odor of the amniotic fluid. D. Administer glucocorticoids intramuscularly.

Correct Answer is C

Explanation

C. Foul-smelling amniotic fluid (often described as having a strong, unpleasant odor) can indicate infection. It provides additional information to support the suspicion of chorioamnionitis.

A. This option is not immediately necessary based solely on an elevated temperature. Emergency cesarean section is indicated for fetal distress or obstetrical emergencies like placental abruption. However, without those indications, it is premature to proceed directly to cesarean section solely due to maternal fever.

B. Delaying action for 4 hours is not appropriate in this scenario. A fever in a pregnant woman with ruptured membranes warrants immediate evaluation and treatment to prevent complications such as maternal sepsis and neonatal infection.

D. Glucocorticoids are administered to enhance fetal lung maturity in cases of preterm birth between 24 and 34 weeks of gestation, not in response to maternal fever. Therefore, this action is not appropriate in this situation.

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A nurse is assessing a newborn who has Trisomy 21 (Down's Syndrome). Which of the following are common characteristics? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

Correct Answer is C

Explanation

A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9° C (102° F). Besides notifying the provider, which of the following is an appropriate nursing action?

Correct Answer is C

Explanation

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