When the infant's toes hyperextend and the big toe dorsiflexes when sole of foot is stroked. This Reflex is called
Babinski Reflex
Rooting
Plantar Flexion
Moro
The Correct Answer is A
The Babinski reflex is present in newborns and occurs when the sole of the foot is stroked from heel to toe. The infant's big toe dorsiflexes (moves upward) and the other toes fan out. This is a normal response in infants up to 12-24 months but is abnormal in older children and adults, where it may indicate neurological issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) The vaccine is a live virus and may cause birth defects in the fetus:
The Rubella vaccine is a live attenuated virus, which means it contains a weakened form of the virus. Although this vaccine is safe for most adults, it can cause serious birth defects if a woman becomes pregnant within a 4-week period after receiving the vaccine. The live virus could potentially affect the developing fetus, causing congenital rubella syndrome (CRS), which can result in severe birth defects like heart defects, deafness, and cataracts. To prevent any risk to a future pregnancy, women are advised to wait at least 4 weeks after
vaccination before trying to conceive.
B) Tests to determine if the client developed immunity are not accurate for a month:
This is not accurate. While some tests for rubella immunity can be done soon after vaccination, the primary reason for delaying pregnancy is the live virus in the vaccine, not a delay in testing. The immune response to the vaccine typically develops within a few weeks, but the risk to a fetus comes from the live virus, not the testing process. The 4-week delay is to ensure that the virus has been cleared from the body before pregnancy is attempted.
C) She may have the virus and feel too sick to tolerate a pregnancy:
While the Rubella vaccine can cause mild side effects like fever, it does not typically cause significant illness that would prevent a woman from tolerating a pregnancy. The primary concern is the safety of the fetus, not the mother's symptoms, as any illness is generally mild and transient. The 4-week delay is to prevent potential harm to a fetus due to the live virus present in the vaccine.
D) Her body is not ready to nurture another pregnancy so quickly:
This rationale is not based on any medical guideline. There is no evidence to suggest that the body needs time to "recover" from the Rubella vaccine before becoming pregnant. The reason for the 4-week delay is to ensure that the live virus has been cleared from the body to avoid any risk to a potential pregnancy. The concern is not about the woman's ability to support another pregnancy, but about the potential for the live vaccine virus to harm a developing fetus.
Correct Answer is A
Explanation
A) Excessive uterine bleeding: A distended bladder can cause the uterus to become displaced to the right, preventing it from contracting effectively. This lack of uterine contraction can lead to uterine atony, which is a significant risk factor for excessive postpartum bleeding. When the uterus cannot contract well, it may result in continued
hemorrhage, which is a serious and immediate concern for postpartum patients.
B) A bladder rupture: While bladder rupture is a rare and severe complication, it is unlikely to occur in this situation. Bladder distention is a concern, but the most immediate danger is related to the uterus, not the bladder itself. A rupture would require significant trauma or extreme overdistention of the bladder, neither of which are described here.
C) Bladder wall atony: Bladder wall atony, where the bladder loses its ability to contract and expel urine, is not the most serious immediate consequence of bladder distention postpartum. While it may be uncomfortable and problematic, the main concern in this scenario is how bladder distention affects uterine contraction, which can lead to excessive bleeding.
D) Urinary tract infection: Although urinary retention can increase the risk of urinary tract infections (UTIs) due to incomplete bladder emptying, this is a less immediate and life-threatening concern compared to excessive bleeding. The primary concern in the immediate postpartum period is the potential for hemorrhage from uterine atony, which is worsened by bladder distention.
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