A nurse is preparing to examine a post-term newborn immediately following delivery. Which of the following findings should she expect to observe? (Select all that apply.).
Moro reflex.
Vernix in the folds and creases.
Abundant lanugo.
Heel to ear maneuverability.
Correct Answer : A
Choice A rationale:
The Moro reflex is a normal finding in newborns, including those born post-term. It is a primitive reflex that should be present and indicates a healthy neurological system.
Choice B rationale:
Vernix, a protective white substance that coats the skin in utero, is typically absent or minimal in post-term newborns due to its decreased production as gestation progresses. Therefore, it would not be expected in a post-term infant.
Choice C rationale:
Lanugo, the fine hair covering a newborn's body, is usually present in greater amounts in preterm infants. By the time a newborn is post-term, lanugo is typically sparse or absent, making it an unlikely finding.
Choice D rationale:
This maneuver assesses the flexibility of the newborn's joints. Post-term infants tend to have reduced flexibility and increased muscle tone, making this maneuver more difficult or restricted in this population.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The Moro reflex, also known as the startle reflex, is a normal reflex observed in newborns. To elicit this reflex, the nurse should perform a sharp hand clap or make a loud noise near the infant. This reflex is characterized by the baby's arms and legs extending outward, followed by a quick flexion, resembling a startle response. It is an important reflex to assess the newborn's neurological and motor development.
Choice B rationale:
Turning the newborn's head quickly to one side does not elicit the Moro reflex. This action may stimulate other reflexes, such as the tonic neck reflex, but it is not the appropriate method to assess the Moro reflex.
Choice C rationale:
Placing a finger at the base of the newborn's toes does not elicit the Moro reflex. This action is more related to testing the Babinski reflex, which involves the fanning and curling of the toes when the sole of the foot is stimulated.
Choice D rationale:
Holding the newborn vertically and allowing one foot to touch the crib surface does not elicit the Moro reflex. This action might elicit the stepping reflex, where the baby shows stepping movements as if walking when held in an upright position with their feet touching a surface.
Correct Answer is ["A","C","D","F"]
Explanation
Choice A rationale:
The newborn reflex called "rooting”. is characterized by turning the head and opening the mouth when the cheek or mouth area is touched. This reflex helps the newborn find the mother's breast for feeding.
Choice B rationale:
"Stepping”. is a newborn reflex where they make stepping movements when held upright with their feet touching a solid surface. This reflex is present at birth but tends to disappear after a few weeks.
Choice C rationale:
The "Moro”. reflex is also known as the startle reflex. It is elicited by a sudden loss of support or loud noise, causing the newborn to throw their arms and legs out and then bring them back in. This reflex usually disappears around 3 to 4 months of age.
Choice D rationale:
The "Babinski”. reflex is characterized by the extension of the big toe and fanning of the other toes when the sole of the foot is stroked. This reflex is present in newborns and should disappear by around 12 months of age.
Choice E rationale:
"Running”. is not a recognized newborn reflex. There is no reflex with this name related to newborns.
Choice F rationale:
The "gag”. reflex is present in newborns and helps protect the airway by causing a gagging response when the back of the throat is stimulated.
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