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'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 newborn closes their eyes and keeps them closed when tapped on the forehead.
The Correct Answer is C
A. This describes the stepping reflex, which involves the newborn's legs moving in a stepping motion when the soles of the feet touch a surface, not just flexing at the knees and hips. It is expected but not the most relevant to the of reflex elicitation as stated.
B. The newborn turns toward the stimulus when their cheek is touched, not away. This is known as the rooting reflex, which helps the newborn find the breast or bottle for feeding.
C. The newborn's fingers curling around the nurse's finger is the grasp reflex, a normal and expected finding in newborns. It indicates normal neurological development and reflex activity.
D. The newborn blinking in response to a tap on the forehead is known as the glabellar reflex, but they do not typically keep their eyes closed. It is not a primary reflex assessed in newborns for neurological health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Nausea is a common side effect of terbutaline but does not typically require urgent reporting. It can be managed with supportive care or adjustments in therapy.
B. Crackles in the lungs are a serious side effect of terbutaline, which can cause pulmonary edema due to fluid retention. This finding indicates a potential adverse reaction that must be reported to the provider for further evaluation and management.
C. Dizziness can occur with terbutaline use but is not as immediately concerning as other potential side effects. It may be managed by adjusting the dose or monitoring the client.
D. Tremors are a common and less severe side effect of terbutaline, typically caused by its beta-adrenergic effects. While they are uncomfortable, they are not an immediate concern compared to more severe reactions.
Correct Answer is []
Explanation
- Potential Condition: Hyperemesis Gravidarum
Actions to take
- Insert a peripheral venous access device:
- Monitor and manage electrolyte values:
Parameters to monitor
- Electrolyte values:
- Urine ketones:
Rationale
- Potential Condition: Hyperemesis Gravidarum
- This condition is characterized by severe nausea and vomiting, leading to dehydration and nutrient loss, which can affect both the mother and fetus.
- Actions to Take:
1. Insert a peripheral venous access device:
- This will allow for the administration of IV fluids and medications to treat dehydration and correct electrolyte imbalances.
2. Monitor and manage electrolyte values:
- Given the client's low potassium levels, it's crucial to monitor and manage electrolytes to prevent complications.
- Parameters to Monitor:
1. Electrolyte values:
- Monitoring electrolyte levels is essential to ensure they are within normal ranges and to adjust IV fluid composition as needed.
2. Urine ketones:
- Positive urine ketones indicate that the body is using fat for energy due to inadequate glucose utilization, which is common in Hyperemesis Gravidarum. Monitoring will help assess the effectiveness of treatment and nutritional status.
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