Nokea
What assessment findings should lead the nurse to suspect Down syndrome in a newborn?
- A. Hypertonia and dark skin
- B. Low-set ears and a simian crease
- C. Inner epicanthal folds and a high, domed forehead
- D. Long, thin fingers and excessive hair
Correct Answer: B
Rationale: Manifestations of the Down syndrome infant include low-set ears, simian crease, protruding tongue, and hypotonic extremities.
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Which is a causative factor of Hirschsprung disease?
- A. Frequent evacuation of solids, liquid, and gases
- B. Excessive peristaltic movement
- C. The absence of parasympathetic ganglion cells in a portion of the colon
- D. One portion of the bowel telescoping into another
Correct Answer: C
Rationale: The causative factor in Hirschsprung disease is the absence of parasympathetic ganglion cells in a portion of the colon.
What is the priority patient problem for the parents of a newborn born with cleft lip and palate?
- A. Parental role conflict
- B. Risk for delayed growth and development
- C. Risk for impaired attachment
- D. Anticipatory grieving
Correct Answer: C
Rationale: Parents of a child with cleft lip and palate may have difficulty bonding with their child due to the appearance of the child. The priority patient problem is risk for impaired attachment. A goal is to promote bonding between parents and infant.
What is the most common clinical manifestation of coarctation of the aorta?
- A. Clubbing of the digits
- B. Upper extremity hypertension
- C. Pedal edema and portal congestion
- D. Loud systolic ejection murmur
Correct Answer: B
Rationale: Coarctation of the aorta results in hypertension in the upper extremities. The pressure in the arms is typically 20 mm Hg higher than in the legs.
The nurse instructs the parents of a child who has had a myringotomy to place the child in which position?
- A. Supine
- B. On the affected side
- C. On the unaffected side
- D. In a Trendelenburg's position
Correct Answer: B
Rationale: Lying on the affected side facilitates ear drainage following a myringotomy.
The nurse anticipates that the cerebrospinal fluid (CSF) taken from a child with bacterial meningitis would have a low
Correct Answer: glucose
Rationale: The glucose level in the CSF of a child with bacterial meningitis is low because the bacteria in the fluid have digested the glucose.