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A nurse is assisting a client with breastfeeding.
The nurse explains that which of the following reflexes will promote the newborn to latch?

A.

Babinski.

B.

Stepping.

C.

Rooting.

D.

Moro.

Answer and Explanation

The Correct Answer is C

Choice A rationale
The Babinski reflex is a normal reflex in infants that disappears by 12 months of age. It involves fanning out of the toes when the sole of the foot is stroked, and it doesn’t promote latching during breastfeeding.
Choice B rationale
The stepping reflex is a primitive reflex that makes newborns appear to take steps or dance when held upright with their feet touching a solid surface. It doesn’t promote latching during breastfeeding.
Choice C rationale
The rooting reflex helps promote latching during breastfeeding. When the corner of the baby’s mouth is touched, the baby will turn his or her head and open his or her mouth to follow and “root” in the direction of the stroking. This helps the baby find the breast or bottle to start feeding.
Choice D rationale
The Moro reflex, also known as the startle reflex, involves the baby throwing back his or her head, extending out the arms and legs, crying, then pulling the arms and legs back in. It doesn’t promote latching during breastfeeding.
 


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Related Questions

Correct Answer is A

Explanation

Choice A rationale
Late decelerations on the fetal monitor are a sign of fetal hypoxia, which means the baby is not getting enough oxygen. The priority nursing action is to position the client on her side, preferably the left side. This position improves blood flow to the uterus and the baby, potentially improving oxygenation.
Choice B rationale

Administering oxygen via face mask can also improve fetal oxygenation, but it is not the first action the nurse should take. Repositioning the client is a quicker intervention and often resolves the issue.
Choice C rationale
Elevating the client’s legs will not improve fetal oxygenation and is not a priority action when late decelerations are noted on the fetal monitor.
Choice D rationale
Increasing the infusion rate of the IV fluid can improve maternal blood volume and cardiac output, potentially improving blood flow to the uterus and the baby. However, it is not the first action the nurse should take when late decelerations are noted.

Correct Answer is B

Explanation

Choice A rationale
Massaging the fundus is not necessary in this case. The fundus is firm, which indicates that the uterus is well contracted and there is no risk of postpartum hemorrhage. Massaging a well- contracted uterus can lead to uterine involution or even inversion.

Choice B rationale
Having the patient urinate is the correct action. A displaced fundus can be a sign of a full bladder. The bladder can push the uterus to the side and prevent it from contracting properly. By emptying the bladder, the uterus can return to its proper position and continue to contract to prevent bleeding.
Choice C rationale
Inserting a urinary catheter is not the first step. The nurse should first ask the patient to urinate. If the patient is unable to urinate, then a catheter may be necessary.
Choice D rationale
Administering an analgesic is not related to the position of the fundus. Pain management is important in postpartum care, but it is not the reason for a displaced fundus.

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