A nurse is collecting data from a newborn who was born at 31 weeks of gestation.
Which of the following findings should the nurse anticipate?
Lack of a startle reflex.
Inability to grasp.
Undescended testes.
Inability to suck.
The Correct Answer is C
Choice A rationale
Choice A rationale:
The startle reflex, or Moro reflex, is typically present in infants born as early as 28 to 32 weeks of gestation, though it may be less sustained than in full-term infants. It is a primitive fight-or-flight response to a sudden loss of support or a loud noise. Finding a complete lack of this reflex in a 31-week neonate would be an abnormal neurological finding rather than an expected characteristic of prematurity. The central nervous system is sufficiently developed by this stage to exhibit basic reflexive movements.
Choice B rationale
Choice B rationale:
The palmar grasp reflex begins to appear around 28 weeks of gestation and becomes more established by 31 weeks. While the grip of a preterm infant may be weaker than that of a term baby, the fundamental neurological pathways for the reflex are intact. An absolute inability to grasp would suggest a significant neurological impairment rather than just prematurity. Nurses expect to see some level of finger flexion when the palm is stimulated, signifying appropriate development for this gestational age.
Choice C rationale
Choice C rationale:
In male fetuses, the descent of the testes from the abdomen into the scrotal sac usually occurs during the third trimester, typically between 28 and 34 weeks of gestation. At 31 weeks, it is a very common and expected finding to observe undescended testes, as the process may not yet be complete. This is a standard anatomical characteristic of prematurity. Clinical monitoring is necessary as most testes will eventually descend spontaneously as the infant grows postnatally or reaches a corrected term age.
Choice D rationale
Choice D rationale:
The coordination of sucking, swallowing, and breathing is a complex developmental milestone that usually matures around 32 to 34 weeks of gestation. While a 31-week infant may have a weak or disorganized suck, the total inability to suck is not always the expectation, as some rudimentary sucking behavior is often present. However, the lack of full coordination means these infants usually require enteral feeding via a nasogastric tube until their neurological and muscular systems are sufficiently mature to handle oral feedings safely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
This response provides clear, evidence-based guidance without being judgmental. There is no known safe amount of alcohol consumption during pregnancy, and any intake can lead to Fetal Alcohol Spectrum Disorders. By stating that no alcohol is recommended for the best outcomes, the nurse establishes a firm clinical boundary while focusing on the health of the fetus. This approach empowers the client with factual information to make an informed decision regarding her prenatal health.
Choice B rationale
This statement is scientifically inaccurate and uses fear-based tactics, which is non-therapeutic. While alcohol is a known teratogen that can cause significant structural and functional brain damage, growth restriction, and facial dysmorphology, it does not typically cause the fetal heart to stop beating immediately after one glass of wine. Providing false information undermines the nurse's credibility and may cause unnecessary extreme anxiety for the client if she has already consumed alcohol.
Choice C rationale
This response is dangerously incorrect. While the first trimester is a critical period for organogenesis, alcohol consumption in the second and third trimesters also poses severe risks. Alcohol exposure later in pregnancy can interfere with complex brain development, leading to cognitive impairments, behavioral issues, and learning disabilities. Suggesting that the baby will be okay if alcohol is consumed after the first trimester neglects the lifelong risks associated with Fetal Alcohol Spectrum Disorders.
Choice D rationale
This response is highly non-therapeutic because it uses a "why" question, which often sounds accusatory and judgmental. It shames the client for her feelings of being overwhelmed and for her inquiry, which can shut down the therapeutic relationship. Instead of exploring the client's stress and providing support or coping mechanisms, this response creates a defensive atmosphere and discourages the client from being honest with the healthcare team in the future.
Correct Answer is A
Explanation
Choice A rationale
Ballottement is a probable sign of pregnancy characterized by the passive movement of the unengaged fetus. When the provider performs a vaginal examination and applies a sudden upward tap against the cervix, the fetus floats upward in the amniotic fluid and then sinks back to touch the examiner's finger. This technique relies on the buoyancy of the fetus within the amniotic sac and is typically assessable during the second trimester of pregnancy.
Choice B rationale
Goodell's sign refers to the significant softening of the vaginal portion of the cervix, which is a probable sign of pregnancy. This change occurs around the beginning of the second month of gestation and is caused by increased vascularity, congestion, and hypertrophy of the cervical glands. While it indicates the hormonal and physiological changes of pregnancy, it does not involve the physical sensation of fetal movement felt by the provider during upward cervical pressure.
Choice C rationale
Lightening is the clinical term for the descent of the fetal head into the true pelvis, which typically occurs toward the end of the third trimester. This shift reduces pressure on the diaphragm, making it easier for the pregnant individual to breathe, but increases pressure on the bladder. It is a physiological event related to the onset of labor and engagement rather than a diagnostic sign of fetal movement elicited during a pelvic examination.
Choice D rationale
Chadwick's sign is a probable sign of pregnancy identified by a bluish or purplish discoloration of the cervix, vagina, and labia. This color change is caused by increased blood flow and venous congestion in the pelvic region due to rising estrogen levels. Like Goodell's sign, it is an anatomical observation during a physical exam but does not relate to the mechanical displacement and return of the fetus known as ballottement.
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