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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. The nurse should not allow anyone other than the mother or the father to take the newborn to the mother's room. This is to prevent infant abduction, which is a serious threat in hospitals. The nurse should also verify the identity of the mother or the father before handing over the newborn. The nurse should instruct the grandmother to have the mother call and request for the newborn to be brought to her room.
B. This is incorrect because pushing the baby in a wheeled bassinet is not a secure way of transporting the newborn. The bassinet could be easily taken by someone else or accidentally rolled away. The nurse should always accompany the newborn when moving from one place to another.
C. This is incorrect because carrying the grandchild to the room is also not a secure way of transporting the newborn. The grandmother could be stopped by someone who claims to be a staff member and asked to hand over the newborn. The nurse should never let anyone carry the newborn without proper identification and authorization.
D. This is incorrect because showing photo identification is not enough to prove that the person is related to the newborn. The nurse should only allow the mother or the father to take the newborn, and only after verifying their identity with a wristband or a code. The nurse should not rely on photo identification alone, as it could be forged or stolen.

A. Fundus palpable to right of midline B. Less than 2.5 cm of rubra lochia on perineal pad C. Client report of increased thirst D. Client report of frequent uterine contractions

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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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother's room. Which of the following is an appropriate response by the nurse?

Correct Answer is A

Explanation

A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

Correct Answer is A

Explanation

A nurse is caring for a client who is 12 hr postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

A woman gave birth to a 7-pound, 6-ounce infant girl 1 hour ago. The birth was vaginal and the estimated blood loss (EBL) was 1500 ml. When evaluating the woman's vital signs, which finding would be of greatest concern to the nurse?

The most serious complication of an infant heelstick is necrotizing osteochondritis resulting from lancet penetration of the bone. What approach should the nurse take when performing the test to prevent this complication?

A nurse is discussing the storage of breast milk with a mother whose infant is preterm and in the special care nursery. Which statement indicates that the mother requires additional teaching?

A new mother asks the nurse what the "experts say" about the best way to feed her infant. Which recommendation of the American Academy of Pediatrics (AAP) regarding infant nutrition should be shared with this client?

A nurse places a newborn under a radiant heat warmer after birth. The purpose of this action is to prevent which of the following in the newborn?

A nurse is caring for a client who is postpartum who asks the nurse when her breast milk will "come in." Which of the following responses should the nurse make?

A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care?