A nurse in the newborn nursery is caring for an infant who has trisomy 21. When collecting data, which of the following findings should the nurse expect?
A single crease in the palm.
A notch in the lip.
An inversion of the foot.
Extra digits on the hand.
The Correct Answer is A
Choice A rationale
A single crease in the palm, known as a simian crease, is a common characteristic seen in infants with trisomy 21 (Down syndrome) due to the unique hand structure associated with this condition.
Choice B rationale
A notch in the lip, such as a cleft lip, is not commonly associated with trisomy 21 and is more typically related to other genetic conditions or environmental factors during development.
Choice C rationale
An inversion of the foot, such as clubfoot, is not a specific characteristic of trisomy 21. This condition is more often seen in other congenital anomalies not related to Down syndrome.
Choice D rationale
Extra digits on the hand, or polydactyly, is not commonly associated with trisomy 21 but can be seen in other genetic disorders. Trisomy 21 has more specific physical features like the simian crease.
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Correct Answer is D
Explanation
Choice A rationale
Nausea can be a side effect of magnesium sulfate, but it is not a specific indication of toxicity. Other symptoms are more directly indicative of magnesium sulfate overdose.
Choice B rationale
Facial flushing is a common side effect of magnesium sulfate but is not a sign of toxicity. It typically occurs at therapeutic levels and is not a reliable indicator of overdose.
Choice C rationale
Urine output of 40 mL/hr is within normal limits for an adult and does not indicate magnesium sulfate toxicity. However, significantly decreased urine output could be concerning.
Choice D rationale
Respiratory rate of 10/min is a critical sign of magnesium sulfate toxicity. Magnesium sulfate can cause respiratory depression, and a rate of 10 breaths per minute or less indicates that the patient may be experiencing toxic effects, necessitating immediate medical intervention.
Correct Answer is B
Explanation
Choice A rationale
Chemotherapy is not a standard treatment for a molar pregnancy unless malignancy is suspected or confirmed. It is usually monitored with regular HCG levels and follow-up.
Choice B rationale
Attending a support group is crucial for emotional support and ensuring that the client has access to resources and information about recovery and future pregnancy planning.
Choice C rationale
Home palliative services are not typically required after a molar pregnancy unless there are specific complications that necessitate such care. The focus is generally on monitoring HCG levels and follow-up.
Choice D rationale
An amniocentesis is not needed after a molar pregnancy. Follow-up includes HCG level monitoring to ensure all molar tissue is gone and to watch for malignancy, not amniocentesis.