A nurse is preparing to examine a post-term newborn immediately following delivery. Which of the following findings should she expect to observe? (Select all that apply.).
Moro reflex.
Vernix in the folds and creases.
Abundant lanugo.
Heel to ear maneuverability.
Correct Answer : A
Choice A rationale:
The Moro reflex is a normal finding in newborns, including those born post-term. It is a primitive reflex that should be present and indicates a healthy neurological system.
Choice B rationale:
Vernix, a protective white substance that coats the skin in utero, is typically absent or minimal in post-term newborns due to its decreased production as gestation progresses. Therefore, it would not be expected in a post-term infant.
Choice C rationale:
Lanugo, the fine hair covering a newborn's body, is usually present in greater amounts in preterm infants. By the time a newborn is post-term, lanugo is typically sparse or absent, making it an unlikely finding.
Choice D rationale:
This maneuver assesses the flexibility of the newborn's joints. Post-term infants tend to have reduced flexibility and increased muscle tone, making this maneuver more difficult or restricted in this population.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The fit of the newborn's clothes is not a reliable indicator of hydration. It may vary based on the clothing size or style and does not give a direct measure of the newborn's hydration status. This choice is not appropriate for evaluating hydration and is therefore incorrect.
Choice B rationale:
The number of wet diapers per day is an essential measure for assessing a newborn's hydration. In the first few days after birth, the baby should have at least one wet diaper for each day of life (e.g., one wet diaper on day one, two on day two, etc.). Afterward, the newborn should have around 6-8 wet diapers per day, which indicates adequate hydration. This choice is appropriate and the correct answer.
Choice C rationale:
How often the newborn cries can be influenced by various factors, including hunger, discomfort, or sleepiness. While crying can indicate the baby's needs, it is not a specific or accurate measure of hydration status. Therefore, this choice is not appropriate for evaluating hydration and is incorrect.
Choice D rationale:
The newborn's skin turgor is a measure of skin elasticity, commonly used in adults to assess hydration. However, it is not a reliable indicator of hydration in newborns, as their skin is more elastic and different from adult skin. Skin turgor is not a suitable parameter to evaluate newborn hydration, making this choice incorrect.
Correct Answer is B
Explanation
Rooting. Choice A rationale:
The Moro reflex is a startle reflex characterized by the infant's sudden extension and abduction of the arms in response to a loud noise or sudden movement. It is not involved in the initiation of sucking and is unrelated to breastfeeding.
Choice B rationale:
The rooting reflex is a crucial reflex that helps initiate sucking in newborns. When the infant's cheek is stroked or touched, they will turn their head toward the stimulus and open their mouth, preparing for feeding. This reflex helps the infant find the mother's nipple and begin breastfeeding effectively.
Choice C rationale:
The stepping reflex is a primitive reflex observed in newborns when held upright with their feet touching a solid surface. The baby will make stepping movements, mimicking walking. However, this reflex is not related to the initiation of sucking and breastfeeding.
Choice D rationale:
The Babinski reflex is a reflex in which the big toe extends upward and the other toes fan out when the sole of the foot is stimulated. This reflex is present in newborns and disappears as the child grows older. It is not involved in the initiation of sucking.
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