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
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.
Correct Answer is C
Explanation
Choice A. Accelerations are normal responses that indicate the fetus is healthy and active. Accelerations occur when the fetal heart rate increases in response to stimuli. •
Choice B. Late decelerations are nonreassuring patterns that indicate fetal hypoxia due to placental insufficiency. Late decelerations occur when the placental blood flow decreases due to uterine contractions during labor, causing the fetal heart rate to decrease. •
Choice C. Variable decelerations are nonreassuring patterns that indicate fetal hypoxia due to umbilical cord compression. Variable decelerations occur when the umbilical cord is trapped by the cervical opening or the fetal body part, twisted, or knotted, causing the fetal oxygen supply to be impaired and the fetal heart rate to drop sharply. •
Choice D. Early decelerations are reassuring patterns that indicate a neural reflex due to fetal head compression. Early decelerations occur when the fetal head is compressed by uterine contractions during labor, causing the parasympathetic nervous system to be stimulated and the heart rate to decrease. The correct answer is C. Variable decelerations are the most common pattern that indicates a problem with the umbilical cord and requires urgent intervention.
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