Exhibits

Here are the questions from the mix up well completed.

The nurse is assisting with planning care for the client. After review of the client's electronic medical record (EMR), which of the following interventions should the nurse recommend as anticipated, nonessential, or contraindicated?

Choice A rationale

This describes the glabellar reflex (or blink reflex), where tapping the bridge of the nose or forehead causes a newborn to blink. However, in newborns, repeated tapping will cause the newborn to continue to blink for the first few taps and then eventually stop or habituate, they do not keep their eyes closed after being tapped.

Choice B rationale

This describes the stepping reflex, where the newborn attempts to 'walk' when held upright with their feet touching a surface. The response described, where the legs flex at the knees and hips when pressure is applied to the soles, is the positive support reflex, which involves extending the legs to bear weight, or the crossed extension reflex, but not the expected finding of a simple application of pressure.

Choice C rationale

Touching the newborn's cheek is meant to elicit the rooting reflex. The expected finding is that the newborn will turn their head toward the stimulus and open their mouth, searching for the breast or bottle. Turning the head away from the stimulus indicates an absent or abnormal rooting reflex.

Choice D rationale

This describes the palmar grasp reflex. When the nurse's finger or an object is placed in the newborn's palm, the newborn's fingers will involuntarily flex and tightly curl around the object. This is an expected and primitive reflex in a term newborn and should be bilaterally symmetrical.

Choice B rationale

A Group B Streptococcus (GBS) culture is routinely performed between 35 and 37 weeks of gestation. This is a screening test to determine if the client is colonized with the bacteria in the vagina or rectum. Positive status indicates the need for intrapartum antibiotic prophylaxis to prevent transmission of GBS to the newborn, which can cause severe neonatal infection.

Choice C rationale

A clean-catch urine specimen is typically collected at the initial prenatal visit to screen for asymptomatic bacteriuria, which can lead to pyelonephritis if untreated. It is not usually performed every two months. Subsequent urinalysis is often done with every prenatal visit to check for protein, glucose, and ketones, which indicate other potential complications.

Choice D rationale

The maternal serum alpha-fetoprotein (MSAFP) screening is a blood test to check for the risk of neural tube defects and chromosomal abnormalities. This test is typically offered between 15 and 20 weeks of gestation, with the optimal time being 16 to 18 weeks, not at 6 weeks. Fetal protein production is insufficient for reliable screening at 6 weeks.

Choice A rationale

A screening for gestational diabetes mellitus (GDM) is generally performed much later in pregnancy, specifically between 24 and 28 weeks of gestation. An earlier screening (e.g., at 12 weeks) is reserved only for clients identified as having significant risk factors (e.g., obesity, family history, previous GDM). The standard screening is the 1-hour glucose challenge test.