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

Moro

Babinski

Stepping

Rooting

Answer and Explanation

The Correct Answer is D

A) Moro reflex:

The Moro reflex is a startle reflex characterized by the newborn's arms and legs extending outward in response to a sudden movement or noise. It is not involved in promoting breastfeeding latching.

B) Babinski reflex:

The Babinski reflex is a reflex action of the newborn's foot in response to stimulation. It involves the toes spreading out and the big toe dorsiflexing when the sole of the foot is stroked. This reflex is unrelated to breastfeeding.

C) Stepping reflex:

The stepping reflex is an automatic response seen in newborns when held upright with their feet touching a solid surface. They make stepping movements with their legs as if they are walking. This reflex is unrelated to breastfeeding.

D) Rooting reflex:

The rooting reflex is a natural instinct in newborns characterized by turning their head toward a stimulus that strokes or touches their cheek or mouth. This reflex helps facilitate breastfeeding by guiding the newborn's mouth toward the nipple, making it easier for them to latch onto the breast and initiate feeding.

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Correct Answer is D

Explanation

A) Assist the family to identify prior use of positive coping skills in family crises:

While assessing coping skills is important, it is not the priority when a client expresses feelings of sadness and potential postpartum depression. The immediate concern is ensuring the safety and well-being of both the mother and newborn.

B) Reinforce postpartum and newborn care discharge teaching:

Reinforcing discharge teaching may be important for overall postpartum care, but it is not the priority when the client is exhibiting symptoms of postpartum depression. Addressing the client's emotional state and safety is more urgent.

C) Anticipate a prescription by the provider for an antidepressant:

While antidepressants may be indicated for postpartum depression, the priority is to assess the client's current state and ensure immediate safety. Initiating medication should be based on a comprehensive assessment and provider's evaluation.

D) Ask the client if she has considered harming her newborn:

This is the priority action. When a client reports feelings of sadness, lack of energy, and wanting to cry, along with other symptoms of postpartum depression, it is crucial to assess for potential harm to herself or her newborn. This question helps determine the severity of the situation and whether immediate intervention is necessary to ensure the safety of both mother and child.

A. Initiate early feeding. B. Suction excess mucus with a bulb syringe. C. Prepare for an exchange blood transfusion. D. Begin phototherapy.

Correct Answer is A

Explanation

A) Initiate early feeding:

Early and frequent breastfeeding or formula feeding helps stimulate bowel movements, which aid in the elimination of bilirubin from the body. Breast milk also contains substances that promote bilirubin excretion, making early feeding an effective preventive measure against neonatal jaundice.

B) Suction excess mucus with a bulb syringe:

While clearing excess mucus can facilitate breathing and feeding, it does not directly prevent jaundice.

C) Prepare for an exchange blood transfusion:

Exchange transfusion is a treatment option for severe jaundice that has not responded to other measures. It is not a preventive measure.

D) Begin phototherapy:

Phototherapy is a treatment for jaundice after it has occurred, not a preventive measure. It involves exposing the newborn's skin to specific wavelengths of light to break down excess bilirubin.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

Correct Answer is D

Explanation

A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

Correct Answer is A

Explanation

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