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 closes their eyes and keeps them closed when tapped on the forehead.
The newborn's legs flex at the knees and hips when pressure is applied to the soles of the newborn's feet.
The newborn turns their head away from the stimulus when their cheek is touched.
The newborn's fingers curl around the nurse's finger when placed in the newborn's palm.
The Correct Answer is D
Choice A rationale
This describes the glabellar reflex (or blink reflex), where tapping the bridge of the nose or forehead causes a newborn to blink. However, in newborns, repeated tapping will cause the newborn to continue to blink for the first few taps and then eventually stop or habituate, they do not keep their eyes closed after being tapped.
Choice B rationale
This describes the stepping reflex, where the newborn attempts to 'walk' when held upright with their feet touching a surface. The response described, where the legs flex at the knees and hips when pressure is applied to the soles, is the positive support reflex, which involves extending the legs to bear weight, or the crossed extension reflex, but not the expected finding of a simple application of pressure.
Choice C rationale
Touching the newborn's cheek is meant to elicit the rooting reflex. The expected finding is that the newborn will turn their head toward the stimulus and open their mouth, searching for the breast or bottle. Turning the head away from the stimulus indicates an absent or abnormal rooting reflex.
Choice D rationale
This describes the palmar grasp reflex. When the nurse's finger or an object is placed in the newborn's palm, the newborn's fingers will involuntarily flex and tightly curl around the object. This is an expected and primitive reflex in a term newborn and should be bilaterally symmetrical.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Applying warm packs during the initial 24 hours postpartum is generally contraindicated for an episiotomy site. Heat promotes vasodilation, which could increase swelling and edema in the traumatized perineal tissues, exacerbating pain and potentially increasing blood loss. Cold therapy, such as ice packs, is the preferred intervention initially, as it causes vasoconstriction, reducing localized edema and numbing the area for pain relief.
Choice B rationale
Encouraging the client to take a sitz bath twice daily is an appropriate intervention for an episiotomy, typically after the first 24 hours postpartum when the initial swelling has subsided. The warm water promotes vasodilation, which improves circulation to the perineal area. This enhanced blood flow facilitates healing and offers soothing relief from pain and discomfort, aiding in tissue regeneration and cleanliness.
Choice C rationale
Applying antibiotic ointment to a routine episiotomy is generally not recommended unless there are signs of infection or a specific prescription is provided. The wound is clean, and the risk of introducing pathogens outweighs the routine benefit. Proper hygiene with cleansing after elimination, using a peri-bottle with warm water, and changing pads frequently is the standard of care to prevent infection and promote natural healing.
Choice D rationale
Instructing the client to wipe the perineum with toilet tissue after voiding is incorrect and can be detrimental to episiotomy healing. Wiping, particularly from back to front, can introduce fecal bacteria into the episiotomy site or vagina, increasing the risk of infection. The client should be instructed to use a peri-bottle filled with warm water to gently rinse the area after elimination and then pat dry with a clean cloth or tissue.
Correct Answer is A
Explanation
Choice A rationale
The Lamaze technique for childbirth preparation utilizes conditioned responses to cope with labor pain, which includes specific signals from the coach, a learned response (like a specific breathing pattern), and relaxation techniques. This approach aims to reduce the perception of pain by focusing attention and promoting muscular release through psychoprophylaxis.
Choice B rationale
Using tennis balls on the sacral area to lean against is a non-pharmacological pain relief technique, but it's a form of counter-pressure applied to the lower back, often effective for back labor, not an instruction specific to the technique of acupressure. Counter-pressure helps to relieve the referred pain caused by the fetus's occiput pressing against the sacrum.
Choice C rationale
Using light, rhythmic strokes on the abdomen, known as effleurage, along with rhythmic breathing, is a touch/massage technique often taught in childbirth classes. It provides a distracting sensory input and promotes relaxation, but it is not the specific method for applying acupressure, which involves sustained pressure on specific body points.
Choice D rationale
Immersing oneself in a tub of warm water is hydrotherapy, a non-pharmacological technique used to relax muscles and reduce pain perception during labor. The warmth promotes vasodilation and aids in relaxation, providing a soothing environment. This method is distinct from the localized pressure application of acupressure.
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