A new mother shows the nurse that her baby grasps her finger when she touches the baby's palm. How might the nurse respond to this information?
"This is a primitive reflex known as the palmar grasp."
"This is a protective reflex known as rooting."
"This is a primitive reflex known as the plantar grasp."
"This is a protective reflex known as the Moro reflex."
The Correct Answer is A
A. "This is a primitive reflex known as the palmar grasp.": The palmar grasp reflex is a primitive reflex observed in newborns where they automatically grasp onto objects (or fingers) that touch
their palms. This reflex typically disappears by around 6 months of age.
B. "This is a protective reflex known as rooting.": Rooting is a reflex where newborns turn their head and open their mouth in response to cheek or mouth stimulation, facilitating breastfeeding. It is not related to grasping objects with the hands.
C. "This is a primitive reflex known as the plantar grasp.": The plantar grasp reflex is similar to the palmar grasp but occurs when pressure is applied to the sole of the foot. It is unrelated to grasping objects with the hands.
D. "This is a protective reflex known as the Moro reflex.": The Moro reflex, also known as the startle reflex, involves the newborn's arms and legs extending and then flexing in response to a sudden movement or loud noise. It is not related to grasping objects with the hands.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The toddler's anterior fontanel is not fully closeD. The closure of the anterior fontanel typically occurs by around 18 months of age. If the fontanel is still open at 3 years old, it may indicate a delay in normal development and could be a cause for concern. The nurse should further assess this finding and consider follow-up with the healthcare provider.
B. The toddler gained 3 in in height since last year: Growth in height is expected during early childhood, and a gain of 3 inches over a year is within the normal range for a 3-year-old.
C. The toddler gained 4 lb in weight since last year: Weight gain is also expected during early childhood, and a gain of 4 pounds over a year is within the normal range for a 3-year-old.
D. The circumference of the child's head increased 1 in since last year: Head circumference typically increases during early childhood as the brain grows, and a 1-inch increase over a year is within the normal range for a 3-year-old.
Correct Answer is ["C","D","E"]
Explanation
A. Use mummy restraints during painful procedures: Using restraints may increase the child's anxiety and resistance, exacerbating the fear of procedures. It is important to minimize any factors that may increase the child's distress during procedures.
B. Perform the procedure as quickly as possiblE. While it is important to minimize the duration of procedures to reduce discomfort, rushing the procedure excessively may increase the child's
anxiety and make the experience more traumatic. A balance should be struck between efficiency and ensuring the child feels comfortable and secure.
C. Have a parent stay with the child during procedures: Having a familiar caregiver present can provide comfort and reassurance to the child during procedures. The presence of a parent can help the child feel safe and supported, reducing anxiety and fear.
D. Cluster invasive procedures whenever possiblE. Clustering invasive procedures minimizes the frequency of painful experiences for the child, reducing overall distress and anxiety. This approach also allows the child to have longer periods of comfort between procedures.
E. Allow the child to keep a toy from home with her: Providing a familiar toy or comfort item can serve as a distraction and source of comfort for the child during procedures. Allowing the child to hold onto something familiar can help reduce anxiety and provide a sense of security.
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