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 A
Explanation
Choice A rationale
When the fetal head is at 3+ station, it means that the baby’s head has moved down the birth canal and is very close to the vaginal opening. At this stage, the nurse should observe for crowning, which is when the widest part of the baby’s head can be seen at the vaginal opening. This is a critical time during labor, and the nurse needs to be prepared for the delivery of the baby.
Choice B rationale
Applying fundal pressure is not recommended as it can cause complications such as uterine rupture, fetal distress, and maternal discomfort. It is also not necessary when the fetal head is at 3+ station as the baby is already moving down the birth canal.
Choice C rationale
Oxytocin is a hormone that can stimulate uterine contractions. However, it is not necessary to prepare to administer oxytocin when the fetal head is at 3+ station. At this stage, the mother’s body is already effectively progressing through labor.
Choice D rationale
Observing for the presence of a nuchal cord, which is when the umbilical cord is wrapped around the baby’s neck, is important throughout labor. However, it is not the primary action the nurse should take when the fetal head is at 3+ station.
Correct Answer is C
Explanation
Choice A rationale
Placing a newborn under a radiant heat warmer after birth does not directly prevent basal metabolic rate reduction. The primary function of a radiant heat warmer is to maintain the newborn’s body temperature and prevent hypothermia.
Choice B rationale
While brown fat production is a mechanism used by newborns to generate heat, placing a newborn under a radiant heat warmer does not stimulate brown fat production.
Choice C rationale
The primary purpose of placing a newborn under a radiant heat warmer after birth is to maintain the newborn’s body temperature. Newborns can lose heat rapidly, as they have a
large surface area compared to their body weight. The radiant heat warmer provides a controlled environment that helps maintain the newborn’s body temperature.
Choice D rationale
Preventing hypothermia is a key reason for placing a newborn under a radiant heat warmer. However, the direct purpose of the warmer is to maintain the newborn’s body temperature.
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