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 B
Explanation
A. Epiglottitis
Epiglottitis typically presents with rapid onset of severe sore throat, high fever, difficulty swallowing, and drooling due to inflammation and swelling of the epiglottis. It is a medical emergency requiring immediate intervention but is less likely to present with the described symptoms.
B. Bronchiolitis
Bronchiolitis commonly occurs in infants and young children, often during the winter months. It is characterized by symptoms such as coughing, wheezing, nasal congestion, fever, and
respiratory distress. The described symptoms, including coughing, nasal congestion, and intermittent fever, align with bronchiolitis.
C. Influenza
Influenza typically presents with symptoms such as fever, cough, sore throat, body aches, and fatigue. While coughing and fever are common symptoms of influenza, the presence of apneic spells is less typical of influenza and more indicative of lower respiratory tract infections like bronchiolitis.
D. Croup
Croup is characterized by a barking cough, hoarseness, and respiratory distress often accompanied by stridor. While croup shares some symptoms with bronchiolitis, such as coughing, the absence of stridor in the description suggests bronchiolitis as a more likely diagnosis.
Correct Answer is A
Explanation
A. An anxiety reaction: The toddler's behavior of sitting quietly, sucking her thumb, and turning away from the nurse when approached after her mother leaves the room suggests anxiety. These
behaviors are common signs of distress or discomfort in young children, especially when separated from their primary attachment figure (in this case, the mother).
B. Regression: Regression involves reverting to earlier, more immature behaviors in response to stress or discomfort. While thumb sucking can be considered a form of regression, the behavior observed in this scenario is more indicative of anxiety rather than a broader regression in
developmental milestones.
C. Resentment toward the mother: There is no evidence in the scenario to suggest that the toddler is expressing resentment toward the mother. The behaviors observed are more likely related to
the child's emotional response to separation and hospitalization.
D. Developing autonomy: Developing autonomy typically involves asserting independence and exploring one's environment. The behaviors observed in the scenario are more indicative of anxiety and distress rather than autonomous behavior.
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