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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"}}
Explanation
- Encourage frequent ambulation: Anticipated. Ambulation can help progress labor, unless contraindicated by the healthcare provider.
- Prepare the client for catheterization: Non-essential. There is no current indication for catheterization as the client is voiding adequately and not in active labor.
- Ensure the client maintains a supine position while in bed: Contraindicated. The supine position can cause supine hypotensive syndrome in pregnant clients. A side-lying position is preferred to optimize blood flow.
- Check FHR every 30 min: Anticipated. Regular monitoring of FHR is important to assess fetal well-being during labor.
- Perform a Nitrazine test: Anticipated. Since the client reports fluid leakage, a Nitrazine test can help confirm if the membranes have ruptured.
- Check client's temperature every hour: Non-essential. The client's temperature is stable, and hourly checks are not indicated unless there are signs of infection or the membrane has been ruptured for an extended period.
- Obtain CBC blood sample: Anticipated. A CBC can help identify any underlying issues such as anemia or infection that could affect labor and delivery.
Correct Answer is ["C","E"]
Explanation
A. Douching is not recommended as it can disrupt the natural vaginal flora and potentially lead to further infections. Instead, maintaining good hygiene without douching is advised.
B. Urinating before bedtime is actually recommended to help flush out bacteria from the urinary tract. Avoiding urination at bedtime can increase the risk of developing a urinary tract infection.
C. Bubble baths can irritate the vaginal area and increase the risk of a urinary tract infection. Pregnant clients should be advised to avoid bubble baths and use mild, unscented soaps instead.
D. Yogurt products are beneficial because they contain probiotics that can help maintain a healthy balance of bacteria in the vagina and urinary tract. Eliminating yogurt from the diet is not necessary and may be counterproductive.
E. Wearing cotton-crotch underwear helps keep the vaginal area dry and reduces the risk of infections. Cotton allows for better air circulation and absorbs moisture compared to synthetic fabrics.
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