The nurse is assessing a newborn after delivery and observes the following: epicanthal folds, heart murmur, low-set ears, and poor muscle tone. What does the nurse suspect?
“Trisomy 21”
“Cystic Fibrosis”
“Tay-Sachs disease”
“Marfan syndrome”
The Correct Answer is A
Choice A rationale:
Epicanthal folds: These are skin folds that cover the inner corners of the eyes. They are a common characteristic of Trisomy 21, also known as Down syndrome.
Heart murmur: A heart murmur is an abnormal sound heard during a heartbeat. It can be caused by a variety of conditions, including Trisomy 21. Approximately half of babies with Down syndrome have a heart defect.
Low-set ears: This means that the ears are positioned lower on the head than usual. This is another common characteristic of Trisomy 21.
Poor muscle tone: This means that the muscles are weak and floppy. This is also a common characteristic of Trisomy 21.
Choice B rationale:
Cystic fibrosis: This is a genetic disorder that affects the lungs and digestive system. It is not typically associated with the physical features observed in this newborn. Newborns with cystic fibrosis typically present with meconium ileus, failure to thrive, and recurrent respiratory infections.
Choice C rationale:
Tay-Sachs disease: This is a rare genetic disorder that affects the nervous system. It is not typically associated with the physical features observed in this newborn. Infants with Tay-Sachs disease typically appear normal at birth, with symptoms developing around 6 months of age. These symptoms can include developmental delays, muscle weakness, seizures, and blindness.
Choice D rationale:
Marfan syndrome: This is a genetic disorder that affects the connective tissue. It is not typically associated with the physical features observed in this newborn. Individuals with Marfan syndrome typically have tall stature, long limbs, and hypermobile joints. They may also have eye problems, such as lens dislocation, and heart problems, such as aortic aneurysm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is C. The test results are normal.
Choice A rationale:
A biophysical profile (BPP) score of 8 does not necessarily indicate a need for immediate cesarean delivery.
Cesarean delivery is typically reserved for cases where there is a clear and urgent risk to the health of the mother or fetus, such as severe fetal distress or placental abruption.
A score of 8, while not the highest possible score, is still within the normal range and does not, by itself, constitute a reason for immediate surgical intervention.
Choice B rationale:
Additional tests may be considered in certain cases, such as when the BPP score is borderline or when there are other risk factors present.
However, a score of 8 is generally considered reassuring and does not typically warrant further testing.
It's essential to evaluate the BPP score in the context of the overall clinical picture, including the gestational age, maternal health, and fetal history.
Choice D rationale:
While an obstetric specialist may review the BPP results and discuss delivery options with the patient, this is not typically done within a week for a score of 8.
A score of 8 indicates reassuring fetal well-being, and there is usually no need for such urgent consultation or decision-making.
The timing of delivery discussions would depend on the overall clinical situation and the patient's individual preferences.
Choice C rationale:
A BPP score of 8 is considered normal.
It suggests that the fetus is well-oxygenated and has normal heart rate, breathing movements, muscle tone, and amniotic fluid levels.
This score does not raise immediate concerns about fetal well-being and does not typically require any immediate interventions.
Correct Answer is A
Explanation
Choice A rationale:
Hispanic women: While Hispanic cultures often emphasize strength and resilience, their expression of pain during labor can vary significantly. Some may vocalize their pain while others may remain more stoic. It's important to avoid generalizations and assess each individual's preferences and needs.
Choice B rationale:
Chinese women: In traditional Chinese culture, stoicism in the face of pain is often valued. This may be rooted in Confucianism, which emphasizes self-control and endurance. Women may be less likely to express their pain during labor to avoid appearing weak or losing face. They may also believe that vocalizing pain could negatively impact the birthing process. However, as labor progresses, they may become more vocal and request pain relief.
Choice C rationale:
Caucasian/European women: Caucasian women exhibit diverse responses to labor pain, influenced by personal experiences, cultural beliefs, and social expectations. Some may express their pain openly, while others may prefer to manage it quietly. It's crucial to avoid stereotyping and provide individualized care.
Choice D rationale:
African-American women: African-American women often express their pain during labor more openly than some other cultural groups. This may be due to historical experiences of racism and discrimination in healthcare, leading to a distrust of medical professionals and a greater reliance on self-advocacy. They may also have a stronger sense of community and support networks that encourage open expression of pain.
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