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 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.
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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