A nurse is collecting data from a newborn who was delivered at 40 weeks of gestation.Which of the following is an expected finding when eliciting reflexes from the newborn?

The newborn's legs flex at the knees and hips when pressure is applied to the soles of the newborn's feet.

The newborn closes their eyes and keeps them closed when tapped on the forehead.

The newborn's fingers curl around the nurse's finger when placed in the newborn's palm.

The newborn turns their head away from the stimulus when their cheek is touched.

Answer and Explanation

The Correct Answer is C

Choice A rationale

The newborn's legs flexing at the knees and hips when pressure is applied to the soles indicates the stepping reflex, an expected response.

Choice B rationale

Newborns do not typically keep their eyes closed when tapped on the forehead; this is not an expected reflex response.

Choice C rationale

The palmar grasp reflex, where the newborn's fingers curl around the nurse's finger, is an expected and normal finding in newborns, indicating healthy neurological function.

Choice D rationale

The rooting reflex, where the newborn turns their head when their cheek is touched, is expected and demonstrates feeding readiness and normal neural development. .

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Correct Answer is B

Explanation

Choice A rationale

Ensuring the client has a full bladder before the procedure is incorrect. A full bladder can cause discomfort during the pelvic examination and may obscure the pelvic organs, making the examination more challenging for the provider.

Choice B rationale

Instructing the client to bear down when the speculum is inserted is correct. Bearing down helps relax the pelvic muscles, making it easier to insert the speculum and perform the examination with minimal discomfort.

Choice C rationale

Encouraging the client to take rapid, shallow breaths during the procedure is incorrect. This can increase anxiety and tension in the pelvic muscles, making the examination more uncomfortable.

Choice D rationale

Applying povidone-iodine to the provider's fingers prior to bimanual examination is incorrect. The standard procedure involves using gloves and lubricant to prevent infection and ensure patient comfort, not povidone-iodine.

A. Use a disposable razor for shaving while taking this medication. B. You should not take oral contraceptives while taking this medication. C. You will be able to stop taking this medication in 2 weeks. D. Take 650 milligrams of aspirin for leg discomfort.

Correct Answer is B

Explanation

Choice A rationale

Using a disposable razor for shaving while taking warfarin can increase the risk of cuts and bleeding, which should be avoided due to the anticoagulant effects of warfarin.

Choice B rationale

Oral contraceptives should not be taken while on warfarin because they can increase the risk of blood clots, counteracting the effect of the anticoagulant.

Choice C rationale

Stopping warfarin in 2 weeks is incorrect advice, as the duration of therapy varies depending on the condition being treated and the individual's response to the medication.

Choice D rationale

Taking 650 milligrams of aspirin for leg discomfort is not advised while on warfarin, as aspirin can increase the risk of bleeding by affecting platelet function and the blood clotting process.

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A nurse is collecting data from a newborn who was delivered at 40 weeks of gestation.Which of the following is an expected finding when eliciting reflexes from the newborn?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with a pelvic examination of a client during their first prenatal visit.Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who is postpartum and receiving warfarin for deep-vein thrombosis.Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

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