Which newborn reflex elicits the following reaction: Head turns to one side - the way the head is facing, the arm/leg is stretched out while the other is bent?
Tonic neck reflex.
Moro reflex.
Startled reflex.
Babinski reflex.
The Correct Answer is A
Choice A reason:
The tonic neck reflex, also called the fencing posture, occurs when a baby's head is turned to one side. The arm and leg on that side stretch out, while the opposite arm and leg bend up at the elbow. This reflex lasts until the baby is about 5 to 7 months old. This reflex matches the description of the question.
Choice B reason:
The Moro reflex, also called the startle reflex, is the baby's reaction to being startled. The cause is often a loud sound, a sudden movement, or even their own cry. As an adult, you may jump or gasp when you are startled. A baby will throw back their head, extend their arms and legs, cry, then pull their arms and legs back in. This reflex does not match the description of the question.
Choice C reason:
The startled reflex is not a distinct reflex in newborns. It is another name for the Moro reflex, which is explained.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is c. Dehydration. A significantly indented anterior fontanelle in a newborn is most commonly a sign of dehydration.
Choice A reason:
Increased intracranial pressure: This statement is incorrect because increased intracranial pressure typically causes a bulging, not indented, fontanelle. Symptoms include irritability, vomiting, and a high-pitched cry.
Choice B reason:
Vernix caseosa: This statement is incorrect because vernix caseosa is a white, cheesy substance covering the skin of newborns, unrelated to fontanelle indentation. It serves as a protective layer for the baby’s skin.
Choice C reason:
Dehydration: This statement is correct. Dehydration in newborns can cause a sunken fontanelle due to the loss of fluid. Other signs include dry mouth, sunken eyes, and fewer wet diapers.
Choice D reason:
Cyanosis: This statement is incorrect because cyanosis refers to a bluish discoloration of the skin due to lack of oxygen, not related to fontanelle shape. It indicates issues with oxygenation or circulation.
Correct Answer is C
Explanation
Choice A reason:
Assisting the client on a bedpan to urinate is important for assessing urinary output and preventing bladder distension. However, in this situation, the priority is to assess and manage postpartum hemorrhage, which is indicated by the excessive bleeding.
Choice B reason:
Increasing the client's fluid intake is generally a good measure for promoting hydration and maintaining blood volume. However, it is not the priority in this scenario of excessive postpartum bleeding.
Choice C reason:
Palpating the client's uterine fundus is the priority nursing intervention at this time. The excessive bleeding indicated by saturating two perineal pads in a 30-minute period suggests postpartum hemorrhage, which can result from uterine atony (failure of the uterus to contract adequately after childbirth). Palpating the fundus allows the nurse to assess if the uterus is firm or boggy, and if it is not contracting properly, immediate interventions can be initiated to control the bleeding.
Choice D reason:
Preparing to administer oxytocic medication (such as oxytocin) can help stimulate uterine contractions and prevent or manage postpartum hemorrhage. However, the priority is to first assess the uterine fundus and confirm the cause of the excessive bleeding before administering any medication.
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