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
Choice A rationale:
Attaching the IV line to the distal port is not a safe practice for oxytocin administration. This is because oxytocin is a high-alert medication that can have serious adverse effects if administered incorrectly. Attaching the IV line to the distal port increases the risk of the medication being infused too quickly, which can lead to uterine hyperstimulation, fetal distress, or even uterine rupture. The safest practice is to attach the IV line to the proximal port, which is closer to the patient's body and allows for slower infusion rates.
Choice B rationale:
Customizing the concentration of oxytocin is not a recommended practice. Oxytocin is available in a premixed solution of 10 units/mL, and this concentration should not be altered. Altering the concentration can lead to dosing errors and increase the risk of adverse effects.
Choice D rationale:
Titrating oxytocin to gravity is not a safe practice. Oxytocin should be administered using an infusion pump that can accurately control the infusion rate. Infusion pumps are necessary to ensure that the medication is administered at the correct dose and rate. Gravity-based infusions are less accurate and can lead to over- or under-infusion of the medication.
Choice C rationale:
Two RN verification is a safe practice for oxytocin administration. This practice involves having two registered nurses independently verify the medication, dose, and infusion rate before administration. This helps to prevent errors and ensure that the medication is administered safely.
Correct Answer is C
Explanation
Choice A rationale:
Incorrect. This statement describes autosomal dominant inheritance, not autosomal recessive inheritance. In autosomal dominant inheritance, only one copy of the abnormal gene is needed to cause the disorder. However, in autosomal recessive inheritance, both copies of the gene must be abnormal for the disorder to be expressed.
Choice B rationale:
Incorrect. This statement describes X-linked recessive inheritance, not autosomal recessive inheritance. In X-linked recessive inheritance, the abnormal gene is located on the X chromosome. Males have only one X chromosome, so if they inherit the abnormal gene, they will have the disorder. Females have two X chromosomes, so they must inherit two copies of the abnormal gene (one from each parent) to have the disorder.
Choice C rationale:
Correct. This statement accurately describes autosomal recessive inheritance. In autosomal recessive inheritance, both copies of the gene must be abnormal for the disorder to be expressed. This means that both parents must be carriers of the abnormal gene in order for their child to have the disorder.
Choice D rationale:
Incorrect. This statement is partially correct, but it does not fully describe autosomal recessive inheritance. The disorder can occur in both males and females, but it is not limited to heterozygous females. Homozygous females (those who have two copies of the abnormal gene) will also have the disorder.
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