While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a C with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive reflex.
Moro reflex
Babinski reflex
Tonic neck reflex
Rooting reflex
The Correct Answer is A
A. The described reflex is the Moro reflex, which is a normal startle reflex in newborns.
B. The Babinski reflex involves the extension of the big toe and fanning of the other toes in response to stroking the sole of the foot.
C. The Tonic neck reflex involves turning the head to one side, with the arm on that side extending and the opposite arm flexing.
D. The Rooting reflex involves turning the head and opening the mouth in response to cheek or mouth stimulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Placing an identification bracelet is important but not the immediate priority after ensuring a patent airway.
B. Drying the skin is a priority to prevent heat loss and promote thermoregulation in the newborn.
C. Administering vitamin K is important but can be done after drying the skin.
D. Administering eye prophylaxis is important but can be done after drying the skin.
Correct Answer is A
Explanation
A. A fundus palpable to the right of midline may indicate a distended bladder pushing the uterus to the side, and it requires intervention to promote bladder emptying.
B. Less than 2.5 cm of rubra lochia on a perineal pad is a normal finding in the early postpartum period.
C. Increased thirst is not directly indicative of bladder distention.
D. Frequent uterine contractions are expected in the postpartum period and do not necessarily indicate bladder distention.
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