The parents of a newborn who is being treated for bacterial septicemia ask the nurse why their baby didn't seem very ill. The best response of the nurse is:
Select one:

"You would have seen more symptoms if you had been looking more closely at your baby."

"A newborn's immune system isn't mature, so symptoms are subtle and can be hard to recognize."

"A high fever will always be present in sick newborns, including your baby."

"A mother's immunity usually protects the infant from illness, but not in this case."

Answer and Explanation

The Correct Answer is B

Choice A Reason: "You would have seen more symptoms if you had been looking more closely at your baby." This is an inappropriate response that blames the parents for missing the signs of sepsis and does not explain the Reason for the subtle symptoms.

Choice B Reason: "A newborn's immune system isn't mature, so symptoms are subtle and can be hard to recognize." This is an appropriate response that educates the parents about the immunological basis of sepsis in newborns and reassures them that they are not at fault for not noticing the symptoms.

Choice C Reason: "A high fever will always be present in sick newborns, including your baby." This is an incorrect response that contradicts the fact that newborns may not develop fever in response to infection due to their immature immune systems.

Choice D Reason: "A mother's immunity usually protects the infant from illness, but not in this case." This is an inaccurate response that implies that the mother failed to provide adequate immunity to her baby and does not address the question of why the baby did not seem very ill.

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Correct Answer is B

Explanation

Choice A Reason: The cheek of the newborn is touched, and the newborn turns toward the side that was touched. This is an incorrect answer that describes a diﬀerent reﬂex called the rooting reﬂex. The rooting reﬂex is a feeding reﬂex that helps the newborn locate the nipple and initiate sucking. The rooting reﬂex is elicited by stroking the cheek or corner of the mouth of the newborn, which causes them to turn their head and open their mouth toward the stimulus.

Choice B Reason: The newborn is suddenly lowered or startled, and they extend their arms, legs and neck, then rapidly bring their arms together. This is because this response describes the Moro reﬂex, which is a primitive reﬂex that is present at birth and disappears by 3 to 6 months of age. The Moro reﬂex is elicited by simulating a falling sensation or a loud noise, which triggers a fear response in the newborn. The Moro reﬂex consists of four phases: extension, abduction, adduction, and crying.

Choice C Reason: The newborn is supine and their head is turned to one side, then the arm on that same side extends. This is an incorrect answer that refers to another reﬂex called the tonic neck reﬂex. The tonic neck reﬂex is a postural reﬂex that helps prepare the newborn for voluntary reaching. The tonic neck reﬂex is elicited by placing the newborn in a supine position and turning their head to one side, which causes them to assume a "fencing" posture with one arm extended and one arm ﬂexed.

Choice D Reason: The lateral aspect of the sole of the newborn's foot is stroked, and the toes extend and fan outward. This is an incorrect answer that indicates a diﬀerent reﬂex called the Babinski reﬂex. The Babinski reﬂex is a neurological reﬂex that tests for spinal cord integrity. The Babinski reﬂex is elicited by stroking the lateral aspect of the sole of the foot from heel to toe, which causes the big toe to dorsiﬂex and the other toes to fan out.

A. "If I go too long overdue, the amniotic ﬂuid volume can become too low for my baby to be safe." B. "My baby took longer to grow, and now she's ready to be born." C. "I don't really need this induction, my baby will come whenever he wants to." D. "Since I am so tired of being pregnant, I am being induced."

Correct Answer is A

Explanation

Choice A Reason: "If I go too long overdue, the amniotic ﬂuid volume can become too low for my baby to be safe." This is a correct answer that indicates that the client understands one of the Reasons for induction of labor at 42 weeks' pregnancy.

Choice B Reason: "My baby took longer to grow, and now she's ready to be born." This is an incorrect answer that shows a misconception about fetal growth and development. Fetal growth does not depend on gestational age alone, but also on genetic, maternal, placental, and environmental factors. A post-term fetus does not necessarily grow faster or larger than a term fetus. In fact, some post-term fetuses may experience intrauterine growth restriction (IUGR), which means slower than expected growth for gestational age.

Choice C Reason: "I don't really need this induction, my baby will come whenever he wants to." This is an incorrect answer that reveals a lack of awareness or acceptance of the need for induction of labor at 42 weeks' pregnancy. Induction of labor is recommended for post-term pregnancies to prevent potential complications such as fetal distress, stillbirth, or maternal hemorrhage.

Choice D Reason: "Since I am so tired of being pregnant, I am being induced." This is an incorrect answer that implies that induction of labor is based on maternal preference or convenience rather than medical indication. Induction of labor should not be done without a valid Reason or informed consent, as it carries some risks such as failed induction, prolonged labor, infection, uterine rupture, or cesarean delivery.

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The parents of a newborn who is being treated for bacterial septicemia ask the nurse why their baby didn't seem very ill. The best response of the nurse is: Select one:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a newborn physical assessment and is about to elicit the Moro reﬂex. Which of the following responses should the nurse expect to see? Select one:

Correct Answer is B

Explanation

The client at 42 weeks' pregnancy is admited for induction of her labor. Which statement indicates that she understands the Reasons for the induction? Select one:

Correct Answer is A

Explanation

When reviewing the causes of late postpartum hemorrhage, which of the following would the nurse identify as the most common cause? Select one:

Before applying a cord clamp, the nurse assesses the umbilical cord for vessels. The nurse expects to find: Select one:

A nurse explains to new parents that their newborn has developed respiratory distress syndrome (RDS). Which of the following assessments that the nurse makes would support a diagnosis of RDS? Select one:

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The nurse's initial action when caring for an otherwise stable, full term infant with a slightly decreased temperature is to: Select one:

The parents of a newborn who is being treated for bacterial septicemia ask the nurse why their baby didn't seem very ill. The best response of the nurse is: Select one:

The nurse assesses a 1-day-old newborn. Which finding indicates that the newborn's oxygenation needs are not being met? Select one:

The parents of a newborn who is being treated for bacterial septicemia ask the nurse why their baby didn't seem very ill. The best response of the nurse is:
Select one: