A nurse is assisting a client with breastfeeding her newborn.
The nurse should explain that which of the following reflexes will initiate sucking?
Rooting.
Moro.
Stepping.
Babinski.
The Correct Answer is A
Choice A rationale:
The rooting reflex is the newborn's natural response to touch around their mouth, particularly the cheek. When the cheek is touched, the infant will turn their head in that direction and open their mouth, initiating the sucking reflex. This reflex helps the newborn find the breast or bottle for feeding.
Choice B rationale:
The Moro reflex is not associated with the initiation of sucking. The Moro reflex is a startle reflex that involves extending and retracting the arms and legs when a newborn feels a sudden loss of support or experiences a loud noise.
Choice C rationale:
The stepping reflex is not related to the initiation of sucking. The stepping reflex is an automatic response that occurs when you hold a newborn upright with their feet touching a surface, causing them to make stepping movements.
Choice D rationale:
The Babinski reflex involves the extension and fanning out of the toes when the sole of the foot is stroked. It is not associated with the initiation of sucking.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Checking the fetal heart rate pattern is the priority nursing action following an amniotomy. This procedure involves rupturing the amniotic membranes, which can result in changes to the baby's heart rate. It's essential to assess the fetal heart rate to ensure the baby is tolerating the procedure well and to identify any signs of fetal distress promptly.
Choice B rationale:
Evaluating the client for signs of infection is an important step after an amniotomy, but it is not the top priority. The immediate concern is the well-being of the fetus, and assessing the fetal heart rate takes precedence.
Choice C rationale:
Taking the client's temperature is relevant to monitor for infection, but it should not be the first action. Monitoring the fetus's status with a fetal heart rate assessment is more critical in this situation.
Choice D rationale:
Observing the color and consistency of amniotic fluid is a valuable assessment but not the top priority. It can provide information about meconium staining or other issues, but assessing the fetal heart rate is more crucial immediately after the procedure.
Correct Answer is A
Explanation
Choice A rationale:
When a pregnant client is Rh negative and the newborn is Rh positive, it can lead to Rh incompatibility issues. This occurs when fetal Rh-positive red blood cells enter the maternal circulation during pregnancy or childbirth, causing the mother's immune system to produce antibodies against Rh-positive blood cells. To prevent Rh sensitization, Rho(D) immune globulin is administered to Rh-negative pregnant clients at specific times during pregnancy and postpartum. This administration is essential to prevent hemolytic disease of the newborn in future pregnancies. The Rho(D) immune globulin prevents the mother's immune system from developing antibodies against Rh-positive blood cells, ensuring that the current pregnancy and future pregnancies remain safe. Therefore, choice A is the correct answer.
Choice B rationale:
If the client is Rh positive and the newborn is Rh positive, there is no need for Rho(D) immune globulin administration. Rh incompatibility issues only occur when the mother is Rh negative, and the newborn is Rh positive. Therefore, choice B is not the correct answer.
Choice C rationale:
When both the client and the newborn are Rh negative, there is no risk of Rh incompatibility, and therefore, Rho(D) immune globulin administration is unnecessary. This situation is not a reason to administer Rho(D) immune globulin. Choice C is not the correct answer.
Choice D rationale:
If the client is Rh positive and the newborn is Rh negative, there is no risk of Rh incompatibility, and Rho(D) immune globulin administration is not required in this scenario. Choice D is not the correct answer.
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