The nurse is assessing a 4-year-old boy whose mother was 40 years old when he was born.
Which finding suggests this child has a genetic disorder?
Inquiry determines the child had feeding problems.
Observation shows nasal congestion and excess mucus.
Inspection reveals low-set ears with lobe creases.
Auscultation reveals the presence of wheezing.
The Correct Answer is C
Choice A rationale
Feeding problems are a common, non-specific finding in early childhood and can be related to many different issues, such as poor latch, reflux, or developmental delays, and are not exclusively indicative of a genetic disorder like Down syndrome. Therefore, this observation is not specific enough to confirm a genetic etiology.
Choice B rationale
Nasal congestion and excess mucus are very common signs of upper respiratory infections or allergic rhinitis in young children. These findings reflect an inflammatory or infectious process in the nasal passages and are not recognized as a primary or specific physical characteristic of a genetic disorder.
Choice C rationale
Low-set ears are a recognized dysmorphic feature or minor congenital anomaly that is often associated with various syndromes, particularly those involving chromosomal abnormalities like Down syndrome, as they reflect atypical fetal development of the first and second branchial arches. Lobe creases, while a potential finding, are less specific than low-set placement.
Choice D rationale
Wheezing suggests obstruction or narrowing in the lower airways, typically associated with conditions like asthma, bronchiolitis, or foreign body aspiration. This is a respiratory symptom related to inflammation and bronchospasm and is not a typical, pathognomonic physical finding of a common genetic disorder.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Having the patient in a clean diaper is a general standard of care, but it is not the primary nursing action during a lumbar puncture (LP) procedure; sterile technique for the procedure site is paramount to prevent infection. The crucial nursing role is safely maintaining the necessary positioning and continuously monitoring the child's physiological status during the invasive procedure.
Choice B rationale
Continuous monitoring of the patient's cardiorespiratory status (heart rate, respiratory rate, oxygen saturation) is the most critical nursing action during an LP, especially in infants and small children who are commonly held in a tightly flexed, side-lying position. This positioning can compromise ventilation, and changes in intracranial pressure may also affect vital signs.
Choice C rationale
The correct position for a lumbar puncture is usually the side-lying position with the back fully rounded (fetal position) to maximize the space between the vertebrae, or occasionally a sitting position, allowing the provider access to the L3-L4 or L4-L5 interspaces. The prone position is not used as it prevents access to the lumbar area for the procedure.
Choice D rationale
While conscious sedation or analgesia is frequently used to minimize movement and discomfort during an LP in children, starting an IV line is not always necessary if a quick, successful procedure is anticipated without sedation, or if alternative routes for sedation are used. The most essential action is the immediate safety and monitoring of the child's vital functions.
Correct Answer is C
Explanation
Choice A rationale
A child with a diagnosed latex sensitivity, especially one with a history of myelomeningocele which carries a high risk, should absolutely wear medical alert identification. This ensures that emergency medical personnel and others are immediately aware of the allergy to prevent exposure to potentially life-threatening latex products.
Choice B rationale
It is crucial to inform all caregivers, including school nurses, teachers, and daycare providers, about the child's latex allergy. This allows them to implement proper avoidance strategies in their respective environments and recognize early signs of a reaction, ensuring the child's safety outside the home.
Choice C rationale
The statement that a product's label always indicates whether it is latex-free is incorrect and indicates a need for further teaching. Many items contain "hidden" latex, and labeling may not be mandatory or always comprehensive, requiring parents to exercise extreme caution and directly inquire about product composition.
Choice D rationale
Complete avoidance of all contact with products containing natural rubber latex is the only definitive way to prevent an allergic reaction in a sensitized child. Exposure, even to airborne particles from latex-containing materials, can trigger reactions ranging from mild skin irritation to severe anaphylaxis.
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