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 B rationale:
"I'll expect the penis to heal within 24 hours" is not an accurate understanding of circumcision care. Circumcision healing typically takes longer than 24 hours, and this statement could lead to unrealistic expectations. It's essential for the parent to understand that healing may take several days to a week, and they should watch for signs of infection or other complications.
Choice C rationale:
"I'll make sure his diaper is loose in the front" is not directly related to circumcision care. While keeping the diaper loose can help prevent irritation and discomfort, it does not address specific care for the circumcision site. This statement does not demonstrate an understanding of the key points of circumcision care.
Choice D rationale:
"I'll apply alcohol swab to his penis during diaper changes" is not recommended for circumcision care. Using alcohol swabs can be too harsh on the sensitive skin of a newborn and may lead to irritation. It's generally advised to clean the area with warm water and mild soap or simply allow it to air dry.
Choice E rationale:
"I wash his penis with warm water and mild soap each day" is a correct understanding of circumcision care. Keeping the circumcision site clean with warm water and mild soap is a recommended practice to prevent infection. However, it's important to avoid vigorous scrubbing or excessive cleaning, as this can also cause irritation.
Correct Answer is D
Explanation
he nurse should document the client's present gravidity (G) as 4.
Here's the breakdown:
- G stands for Gravidity, which is the total number of pregnancies a woman has had, regardless of their outcome.
- The client has had:
- 1 pregnancy terminated by elective abortion
- 1 pregnancy resulting in the birth of twins (counted as one pregnancy)
- 1 spontaneous abortion
- 1 current pregnancy (at 28 weeks)
Therefore, the total number of pregnancies is 4.
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