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. Having a fever during the first week at home is not a normal or expected finding and may indicate an infection, requiring further assessment.
B. Contacting the provider for incisional discharge is a proper response.
C. Not having unrelieved pain in the abdomen is an appropriate expectation.
D. Resuming prenatal vitamins is a normal postoperative recommendation.

A. The baby should be carried in the parent’s arms from the room to the nursery B. The mom should request that a second staff member verify the identity of any questionable person C. Because of infant security systems, the baby can be left unattended in the client’s room D. Parents should be told it is safe to posting photographs of their infant on the Internet

Correct Answer is B

Explanation

A. Carrying the baby in the parent's arms enhances security but does not directly address the prevention of abduction.
B. Verifying the identity of any questionable person by a second staff member is a key measure to prevent infant abduction.
C. Leaving the baby unattended in the client's room is not a safe practice and does not contribute to preventing abduction.
D. Posting photographs of the infant on the Internet can compromise the child's security and is not recommended.

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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 is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following client statements indicates to the nurse that further teaching is needed??

Correct Answer is A

Explanation

Nurses play a critical role in educating parents regarding measures to prevent infant abduction. Which instructions contribute to infant safety and security?

Correct Answer is B

Explanation

A nurse is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn?

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 nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take?

A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn’s maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make?

A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? (Select all that apply.)

A nurse is caring for a client who is postpartum. The nurse should recognize which of the following statements by the client as an indication of inhibition of parental attachment?

A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?

A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the newborn's mouth, which of the following responses should the nurse make?