A nurse is assisting a client with breastfeeding.
The nurse explains that which of the following reflexes will promote the newborn to latch?
Babinski.
Stepping.
Rooting.
Moro.
The Correct Answer is C
Choice A rationale
The Babinski reflex is a normal reflex in infants that disappears by 12 months of age. It involves fanning out of the toes when the sole of the foot is stroked, and it doesn’t promote latching during breastfeeding.
Choice B rationale
The stepping reflex is a primitive reflex that makes newborns appear to take steps or dance when held upright with their feet touching a solid surface. It doesn’t promote latching during breastfeeding.
Choice C rationale
The rooting reflex helps promote latching during breastfeeding. When the corner of the baby’s mouth is touched, the baby will turn his or her head and open his or her mouth to follow and “root” in the direction of the stroking. This helps the baby find the breast or bottle to start feeding.
Choice D rationale
The Moro reflex, also known as the startle reflex, involves the baby throwing back his or her head, extending out the arms and legs, crying, then pulling the arms and legs back in. It doesn’t promote latching during breastfeeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A probable sign of pregnancy includes objective signs observed by an examiner, such as changes in the pelvic organs, enlargement of the abdomen, and positive pregnancy test.
Choice B rationale
Possible signs of pregnancy are those that are subjective and reported by the patient, such as nausea, vomiting, and missed period. These signs could be due to other conditions.
Choice C rationale
Feeling the baby moving, also known as quickening, is a presumptive sign of pregnancy. These are changes felt by the woman herself and can be caused by other conditions.
Choice D rationale
Positive signs of pregnancy are those that are confirmed by the examiner and cannot be caused by any other condition. These include hearing the fetal heartbeat, visualizing the fetus, and feeling the baby move.
Correct Answer is B
Explanation
Choice A rationale
Massaging the fundus is not necessary in this case. The fundus is firm, which indicates that the uterus is well contracted and there is no risk of postpartum hemorrhage. Massaging a well- contracted uterus can lead to uterine involution or even inversion.
Choice B rationale
Having the patient urinate is the correct action. A displaced fundus can be a sign of a full bladder. The bladder can push the uterus to the side and prevent it from contracting properly. By emptying the bladder, the uterus can return to its proper position and continue to contract to prevent bleeding.
Choice C rationale
Inserting a urinary catheter is not the first step. The nurse should first ask the patient to urinate. If the patient is unable to urinate, then a catheter may be necessary.
Choice D rationale
Administering an analgesic is not related to the position of the fundus. Pain management is important in postpartum care, but it is not the reason for a displaced fundus.
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