A nurse is assisting a client with breastfeeding her newborn.
The nurse should explain that which of the following reflexes will initiate sucking?
Rooting.
Moro.
Stepping.
Babinski.
The Correct Answer is A
Choice A rationale:
The rooting reflex is the newborn's natural response to touch around their mouth, particularly the cheek. When the cheek is touched, the infant will turn their head in that direction and open their mouth, initiating the sucking reflex. This reflex helps the newborn find the breast or bottle for feeding.
Choice B rationale:
The Moro reflex is not associated with the initiation of sucking. The Moro reflex is a startle reflex that involves extending and retracting the arms and legs when a newborn feels a sudden loss of support or experiences a loud noise.
Choice C rationale:
The stepping reflex is not related to the initiation of sucking. The stepping reflex is an automatic response that occurs when you hold a newborn upright with their feet touching a surface, causing them to make stepping movements.
Choice D rationale:
The Babinski reflex involves the extension and fanning out of the toes when the sole of the foot is stroked. It is not associated with the initiation of sucking.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Checking the fetal heart rate pattern is the priority nursing action following an amniotomy. This procedure involves rupturing the amniotic membranes, which can result in changes to the baby's heart rate. It's essential to assess the fetal heart rate to ensure the baby is tolerating the procedure well and to identify any signs of fetal distress promptly.
Choice B rationale:
Evaluating the client for signs of infection is an important step after an amniotomy, but it is not the top priority. The immediate concern is the well-being of the fetus, and assessing the fetal heart rate takes precedence.
Choice C rationale:
Taking the client's temperature is relevant to monitor for infection, but it should not be the first action. Monitoring the fetus's status with a fetal heart rate assessment is more critical in this situation.
Choice D rationale:
Observing the color and consistency of amniotic fluid is a valuable assessment but not the top priority. It can provide information about meconium staining or other issues, but assessing the fetal heart rate is more crucial immediately after the procedure.
Correct Answer is D
Explanation
Choice A rationale:
Urinary retention is not a typical sign preceding the onset of labor. It's important to provide accurate information to the client, and this statement is not relevant to signs of impending labor.
Choice B rationale:
A decrease in vaginal discharge is not a typical sign preceding the onset of labor. The client should be informed about changes in cervical mucus, which is part of the mucus plug, but a decrease in vaginal discharge is not a specific indicator of impending labor.
Choice C rationale:
Experiencing a surge of energy is not a typical sign preceding the onset of labor. Some clients may report increased energy before labor, but it's not a reliable indicator for all.
Choice D rationale:
Having a weight gain of 0.5 to 1.5 kilograms is a sign that precedes the onset of labor. This weight gain is often attributed to increased amniotic fluid or edema and is associated with impending labor. This choice is the correct answer.
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