Fundamentals of Nursing Q 297
When assessing a newborn whose mother consumed alcohol during the pregnancy, the nurse would assess for which of these clinical manifestations?
A. Wide-spaced eyes, smooth philtrum, flattened nose
B. Strong tongue thrust, short palpebral fissures, simian crease
C. Negative Babinski sign, hyperreflexia, deafness
D. Shortened limbs, increased jitteriness, constant sucking
Correct Answer: A. Wide-spaced eyes, smooth philtrum, flattened nose
The nurse should anticipate that the infant may have fetal alcohol syndrome and should assess for signs and symptoms of it. These include the characteristics listed in choice A. Fetal alcohol syndrome is a condition in a child that results from alcohol exposure during the mother’s pregnancy. Fetal alcohol syndrome causes brain damage and growth problems. The problems caused by fetal alcohol syndrome vary from child to child, but defects caused by fetal alcohol syndrome are not reversible.
Option B: A single palmar crease is a single line that runs across the palm of the hand. People most often have 3 creases in their palms. A single palmar crease appears in about 1 out of 30 people. Males are twice as likely as females to have this condition. Some single palmar creases may indicate problems with development and be linked with certain disorders.
Option C: Hyperreflexia is a sign of upper motor neuron damage and is associated with spasticity and a positive Babinski sign. In infants with at CST which is not fully myelinated the presence of a Babinski sign in the absence of other neurological deficits is considered normal up to 24 months of age.
Option D: Achondroplasia is the most common form of short-limb dwarfism. It is an autosomal dominant disorder caused by a mutation in the gene that creates the cells (fibroblasts) which convert cartilage to bone. This means, if the gene is passed on by one parent, the child will have achondroplasia.