A nurse is collecting data from a newborn who was delivered at 40 weeks of gestation.
Which of the following is an expected finding when eliciting reflexes from the newborn?
The newborn closes their eyes and keeps them closed when tapped on the forehead.
The newborn's legs flex at the knees and hips when pressure is applied to the soles of the newborn's feet.
The newborn turns their head away from the stimulus when their cheek is touched.
The newborn's fingers curl around the nurse's finger when placed in the newborn's palm.
The Correct Answer is D
Choice A rationale
This describes the glabellar reflex (or blink reflex), where tapping the bridge of the nose or forehead causes a newborn to blink. However, in newborns, repeated tapping will cause the newborn to continue to blink for the first few taps and then eventually stop or habituate, they do not keep their eyes closed after being tapped.
Choice B rationale
This describes the stepping reflex, where the newborn attempts to 'walk' when held upright with their feet touching a surface. The response described, where the legs flex at the knees and hips when pressure is applied to the soles, is the positive support reflex, which involves extending the legs to bear weight, or the crossed extension reflex, but not the expected finding of a simple application of pressure.
Choice C rationale
Touching the newborn's cheek is meant to elicit the rooting reflex. The expected finding is that the newborn will turn their head toward the stimulus and open their mouth, searching for the breast or bottle. Turning the head away from the stimulus indicates an absent or abnormal rooting reflex.
Choice D rationale
This describes the palmar grasp reflex. When the nurse's finger or an object is placed in the newborn's palm, the newborn's fingers will involuntarily flex and tightly curl around the object. This is an expected and primitive reflex in a term newborn and should be bilaterally symmetrical.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Vesicles on the skin, lips, and around the eyes are characteristic findings for a herpes simplex virus (HSV) infection, which is a significant and potentially life-threatening viral infection in a newborn. Candida albicans, a fungus, typically causes superficial mucocutaneous infections and is not associated with vesicular skin lesions unless disseminated, which is rare.
Choice B rationale
A temperature of 37.5°C (99.5°F) is within the normal thermal range for a newborn; normal rectal temperature is 36.5°C to 37.5°C (97.7°F to 99.5°F). While an infection could cause fever, this specific temperature is not necessarily indicative of a Candida infection and is an expected normal finding.
Choice C rationale
Edematous red conjunctivae are classic signs of conjunctivitis (ophthalmia neonatorum), often caused by bacterial pathogens like Chlamydia trachomatis or Neisseria gonorrhoeae, acquired during passage through the birth canal. Candida albicans rarely causes ocular infection unless in immunocompromised infants.
Choice D rationale
White patches on the tongue that cannot be removed with gentle scraping are the pathognomonic sign of oral candidiasis (thrush). This is caused by an overgrowth of the yeast Candida albicans, forming a superficial pseudomembrane composed of yeast, debris, and inflammatory cells on the buccal mucosa and tongue.
Correct Answer is ["C","D"]
Explanation
Choice A rationale
. Decreased urination, or oliguria, is typically associated with fluid volume deficit or impaired renal perfusion, not directly with uncomplicated hyperglycemia. In fact, hyperglycemia causes an osmotic diuresis because the excess glucose filtered by the glomeruli exceeds the renal tubules' reabsorption capacity. This results in the excretion of glucose, which draws water with it, leading to polyuria (increased urination), the opposite of the expected manifestation. Normal blood glucose is 70 to 100 mg/dL.
Choice B rationale
. Shallow respirations are not a characteristic sign of hyperglycemia in a client who is pregnant, unless the condition has progressed to severe diabetic ketoacidosis (DKA). DKA causes a metabolic acidosis, which triggers Kussmaul respirations—deep and labored breathing—as a compensatory mechanism to increase CO_2 elimination and raise the blood pH. Shallow breathing would decrease ventilation.
Choice C rationale
. Increased hunger, or polyphagia, is a classic manifestation of hyperglycemia due to the body's inability to utilize glucose effectively as an energy source, despite high blood glucose levels. The cells signal a state of starvation because glucose cannot enter the cells without sufficient insulin, prompting the release of neuropeptides that stimulate appetite and increased caloric intake.
Choice D rationale
. Increased thirst, or polydipsia, is a direct physiological response to the osmotic diuresis caused by hyperglycemia. The high concentration of glucose in the blood increases the plasma osmolarity, which pulls water from the intracellular space into the vascular space, causing cellular dehydration. This triggers the osmoreceptors in the hypothalamus, stimulating the sensation of thirst to encourage fluid intake.
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