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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Increasing fresh fruit intake may not help with morning sickness and could potentially exacerbate nausea if the fruits are acidic or hard to digest. Bland foods are generally better for managing nausea.
B. Restricting fluids is not recommended for managing morning sickness and can lead to dehydration. Adequate hydration is important, and fluids should be taken throughout the day.
C. Eating dry, bland foods in the morning, such as crackers or toast, can help manage morning sickness by settling the stomach before getting out of bed. This is a commonly recommended strategy for alleviating nausea during early pregnancy.
D. Over-the-counter antacids are not the first-line treatment for morning sickness and might not address the underlying cause of nausea. Dietary changes and other non-medication strategies are generally preferred for managing pregnancy-related nausea.

A. Administer the medication into the deltoid muscle. B. Administer the medication with a 25-gauge needle. C. Administer the medication 12 hr after birth. D. Check the mother's Rh factor prior to administration.

Correct Answer is B

Explanation

A: The deltoid muscle is not typically used for injections in newborns due to their underdeveloped muscle mass. Newborns have limited muscle mass, and the vastus lateralis muscle in the thigh is usually preferred for its larger and more developed muscle mass, which can absorb the medication more effectively.

B: A 25-gauge needle is small enough to minimize discomfort and tissue trauma, yet large enough to administer the medication effectively. This size is commonly used for intramuscular injections in newborns, providing a balance between ease of medication administration and patient comfort.

C: The timing of phytonadione administration is crucial. It is typically given within the first hour after birth to prevent hemorrhagic disease of the newborn, a condition that can lead to serious bleeding problems. Waiting 12 hours could increase the risk of bleeding complications.

D: While the mother's Rh factor is important in other contexts, it is not directly relevant to the administration of phytonadione. Phytonadione is given to prevent vitamin K deficiency bleeding in the newborn, which is not related to the mother's Rh factor. Therefore, checking the Rh factor is not a necessary action before administering phytonadione.

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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?

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A nurse is caring for a client who is at 9 weeks of gestation and reports nausea in the morning that continues until midafternoon. Which of the following actions should the nurse encourage the client to take?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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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?