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. Blood pressure 136/86 mm Hg B. Peripheral edema 2+ bilateral lower extremities C. Lateral deviation of the uterus D. Breasts soft E. Pain rating of 3 on a scale of 0 to 10 F. Uterine tone soft G. Large amount of lochia rubra H. Deep tendon reflexes 1+

Correct Answer is ["C","F","G"]

Explanation

A. Blood pressure 136/86 mm Hg
- The blood pressure reading is slightly elevated but not critically high. Postpartum hypertension can be a concern, but this level does not indicate an immediate risk.
- This reading is consistent with the earlier measurement, suggesting stability.
- Immediate follow-up is not required unless there is a significant increase or additional symptoms are present.
B. Peripheral edema 2+ bilateral lower extremities
- Edema is common in the postpartum period due to fluid shifts and should resolve naturally.
- The consistent 2+ rating indicates no acute change.
- Monitoring is appropriate, but it does not require immediate follow-up unless it worsens or is accompanied by other symptoms.
C. Lateral deviation of the uterus
- A laterally deviated uterus can indicate a displaced uterus, possibly due to a full bladder or other reasons, which requires prompt attention.
- The deviation from the firm, midline position noted earlier could suggest an underlying issue that needs immediate investigation.
- This finding could lead to complications if not addressed promptly.
D. Breasts soft
- Soft breasts are normal postpartum when milk has not yet come in or if the client is not breastfeeding.
- There is no change from the earlier assessment.
- This does not require immediate follow-up as it is a normal finding.
E. Pain rating of 3 on a scale of 0 to 10
- A pain rating of 3 is mild and manageable, especially considering it was 2 earlier.
- This slight increase in pain is expected and can be monitored with routine care.
- It does not necessitate immediate follow-up unless there is a sudden and significant increase in pain.
F. Uterine tone soft
- A soft uterine tone postpartum can indicate uterine atony, which can lead to hemorrhage.
- The change from a previously firm uterus to a soft one is concerning.
- Immediate follow-up is necessary to prevent potential complications such as postpartum hemorrhage.
G. Large amount of lochia rubra
- A large amount of lochia rubra can be a sign of excessive bleeding.
- The increase from a moderate amount earlier to a large amount could indicate a hemorrhagic complication.
- This finding requires immediate follow-up to assess for postpartum hemorrhage.
H. Deep tendon reflexes 1+
- A deep tendon reflex of 1+ is considered within normal limits.
- There has been no change from the earlier assessment.
- This finding does not require immediate follow-up as it is a normal finding.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is ["C","F","G"]

Explanation

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