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 A

Explanation

A. Early ambulation is essential to prevent venous stasis and reduce the risk of thromboembolism. Ambulation helps promote blood circulation in the lower extremities, which is important in preventing blood clots. Walking also aids in restoring normal bowel function and enhances overall recovery after cesarean birth.

B. While warm, moist heat can provide comfort, it does not directly prevent thromboembolic complications. It may help with muscle relaxation and discomfort but is not a primary intervention for clients at risk of thromboembolic disease.

C. Massaging the lower legs could potentially dislodge clots or cause embolization in clients with a history of thromboembolic disease. Therefore, it is contraindicated in this situation as it can increase the risk of complications rather than prevent them.

D. Placing pillows under the knees helps promote comfort and relaxation but does not directly prevent thromboembolic complications. It is a supportive measure rather than a primary intervention for thromboembolism prevention.

A. Assess maternal blood glucose. B. Discontinue the medication infusion. C. Prepare for an emergency cesarean birth. D. Place the client in Trendelenburg position.

Correct Answer is B

Explanation

B. Respiratory depression and absent deep-tendon reflexes are signs of magnesium sulfate toxicity. Discontinuing the infusion is crucial to prevent further magnesium accumulation and worsening of symptoms.

A. Monitoring blood glucose is important in clients receiving magnesium sulfate due to its potential to lower blood glucose levels but it is not the priority in this situation where respiratory depression and absent deep-tendon reflexes are concerning signs of magnesium toxicity.

C. While preeclampsia can sometimes necessitate an emergency cesarean birth if there are severe complications such as eclampsia (seizures), the immediate concern here is managing the magnesium sulfate toxicity rather than proceeding to cesarean birth based on the information provided.

D. Trendelenburg position (head-down) is not indicated in this situation. It does not address the underlying magnesium toxicity and can potentially worsen respiratory depression.

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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 planning care for a client who is 2 hours postpartum following a cesarean birth. The client has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care?

Correct Answer is A

Explanation

A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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