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 D

Explanation

D. Assessing the fetal heart rate (FHR) is the priority action following an amniotomy. Rupture of membranes can sometimes cause umbilical cord prolapse or compression, leading to fetal distress. Monitoring the FHR allows the nurse to identify any abnormalities promptly and intervene as needed to ensure fetal well-being. Continuous monitoring of the FHR is essential after an amniotomy to detect signs of fetal distress early.

A. Providing clean, dry underpads is a routine nursing action after an amniotomy to absorb any amniotic fluid that continues to leak. While this is necessary for maintaining cleanliness and comfort, it is not the immediate priority over other assessments that directly impact client and fetal status.

B. Assessing the odor of amniotic fluid can provide important information about potential infection. Foul- smelling amniotic fluid may indicate chorioamnionitis (infection of the amniotic membranes), which can have serious consequences for both the client and the fetus. While this assessment is important, it is not the immediate priority immediately following the procedure unless there are other signs of infection or fetal distress.

C. Monitoring the client's temperature is a crucial nursing action following an amniotomy. An increase in temperature could indicate infection, particularly chorioamnionitis. Infection can lead to maternal sepsis and adverse outcomes for the fetus. Therefore, assessing and monitoring the client's temperature is a priority to detect early signs of infection and initiate appropriate interventions promptly.

A. 2 cm above the umbilicus B. To the right of the umbilicus C. One fingerbreadth above the symphysis pubis D. At the level of the umbilicus

Correct Answer is C

Explanation

C. This position is more typical 12 hours after vaginal delivery. As involution progresses, the uterine fundus descends approximately one fingerbreadth (about 1-2 cm) below the umbilicus each day. Therefore, one fingerbreadth above the symphysis pubis is a reasonable expectation for the fundal position at this time.

A. 12 hours after vaginal delivery, the uterine fundus typically would not be 2 cm above the umbilicus. This position is more characteristic of where the fundus might be immediately after delivery or within the first few hours. As involution progresses, the fundus descends.

B. The uterine fundus being to the right of the umbilicus is not typical 12 hours after vaginal delivery. The fundus location should be descending in a central position as involution progresses.

D. Immediately after delivery, the uterine fundus is typically at the level of the umbilicus or slightly above. However, 12 hours after vaginal delivery, the fundus should be descending as involution progresses. Therefore, the fundus should not be at the level of the umbilicus at this point.

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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.)

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Correct Answer is C

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