A nurse is assisting a client with breastfeeding her newborn. The nurse should explain that which of the following reflexes will initiate sucking?
Moro.
Rooting.
Stepping.
Babinski.
The Correct Answer is B
Rooting. Choice A rationale:
The Moro reflex is a startle reflex characterized by the infant's sudden extension and abduction of the arms in response to a loud noise or sudden movement. It is not involved in the initiation of sucking and is unrelated to breastfeeding.
Choice B rationale:
The rooting reflex is a crucial reflex that helps initiate sucking in newborns. When the infant's cheek is stroked or touched, they will turn their head toward the stimulus and open their mouth, preparing for feeding. This reflex helps the infant find the mother's nipple and begin breastfeeding effectively.
Choice C rationale:
The stepping reflex is a primitive reflex observed in newborns when held upright with their feet touching a solid surface. The baby will make stepping movements, mimicking walking. However, this reflex is not related to the initiation of sucking and breastfeeding.
Choice D rationale:
The Babinski reflex is a reflex in which the big toe extends upward and the other toes fan out when the sole of the foot is stimulated. This reflex is present in newborns and disappears as the child grows older. It is not involved in the initiation of sucking.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A"]
Explanation
Choice A rationale:
The Moro reflex is a normal finding in newborns, including those born post-term. It is a primitive reflex that should be present and indicates a healthy neurological system.
Choice B rationale:
Vernix, a protective white substance that coats the skin in utero, is typically absent or minimal in post-term newborns due to its decreased production as gestation progresses. Therefore, it would not be expected in a post-term infant.
Choice C rationale:
Lanugo, the fine hair covering a newborn's body, is usually present in greater amounts in preterm infants. By the time a newborn is post-term, lanugo is typically sparse or absent, making it an unlikely finding.
Choice D rationale:
This maneuver assesses the flexibility of the newborn's joints. Post-term infants tend to have reduced flexibility and increased muscle tone, making this maneuver more difficult or restricted in this population.
Correct Answer is D
Explanation
Choice A rationale:
Acrocyanosis, or bluish discoloration of the hands and feet, is common in the first 24 hours after birth and is typically not a cause for concern.
Choice B rationale:
A newborn not voiding within 18 hours may need evaluation, but it is not as urgent as a potential infection.
Choice C rationale:
A newborn who is 24 hours old and has not passed meconium is not the most critical concern among the options provided. While meconium (the baby's first stool) should be passed within the first 24-48 hours, a slight delay may not be an immediate cause for concern.
Choice D rationale:
The nurse should prioritize seeing the newborn with an axillary temperature of 37.8°C (100° F), as this could indicate an infection or other serious condition requiring immediate attention.
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