When the infant's toes hyperextend and the big toe dorsiflexes when sole of foot is stroked. This Reflex is called
Babinski Reflex
Rooting
Plantar Flexion
Moro
The Correct Answer is A
The Babinski reflex is present in newborns and occurs when the sole of the foot is stroked from heel to toe. The infant's big toe dorsiflexes (moves upward) and the other toes fan out. This is a normal response in infants up to 12-24 months but is abnormal in older children and adults, where it may indicate neurological issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
A) The urethra, bladder, and urinary meatus are edematous:
Postpartum women often experience edema in the urethra, bladder, and urinary meatus due to the pressure exerted during delivery. This swelling can make it difficult for the woman to feel the urge to urinate, even when her bladder is full. Encouraging her to urinate every 2 hours helps prevent overdistension of the bladder, which can lead to urinary retention and other complications.
B) She has decreased sensitivity to fluid pressures after a vaginal birth:
After childbirth, especially a vaginal birth, the pelvic floor and surrounding tissues can be numb or less sensitive due to trauma, swelling, and the effects of anesthesia. This decreased sensitivity makes it harder for the woman to sense when she needs to urinate. Encouraging regular voiding even without the urge helps to prevent urinary retention, which is common in the immediate postpartum period.
C) At 12 hours postpartum, she will begin diuresing:
Diuresis, the process of excreting excess fluid retained during pregnancy, typically begins within 12 hours postpartum. This increased urine output can make it even more important for the mother to void regularly to prevent urinary retention. If the bladder is not emptied regularly, it can lead to discomfort and increase the risk of complications like bladder distention or infection.
D) There is no cause for concern as long as the patient urinates once per shift:
This is not true. A postpartum woman should void more frequently than once per shift (which is about every 8 hours). Urinating only once every shift can lead to urinary retention, bladder overdistension, and possible infection. The recommendation to urinate every 2 hours helps ensure proper bladder emptying and reduces the risk of complications.
E) A full bladder can lead to postpartum hemorrhage:
A full bladder can indeed contribute to postpartum hemorrhage (PPH). An overdistended bladder can displace the uterus, preventing it from contracting effectively after delivery. This can increase the risk of excessive bleeding. Regular voiding helps prevent bladder distention and supports uterine contraction, thereby reducing the risk of hemorrhage.
Correct Answer is A
Explanation
A) Excessive uterine bleeding: A distended bladder can cause the uterus to become displaced to the right, preventing it from contracting effectively. This lack of uterine contraction can lead to uterine atony, which is a significant risk factor for excessive postpartum bleeding. When the uterus cannot contract well, it may result in continued
hemorrhage, which is a serious and immediate concern for postpartum patients.
B) A bladder rupture: While bladder rupture is a rare and severe complication, it is unlikely to occur in this situation. Bladder distention is a concern, but the most immediate danger is related to the uterus, not the bladder itself. A rupture would require significant trauma or extreme overdistention of the bladder, neither of which are described here.
C) Bladder wall atony: Bladder wall atony, where the bladder loses its ability to contract and expel urine, is not the most serious immediate consequence of bladder distention postpartum. While it may be uncomfortable and problematic, the main concern in this scenario is how bladder distention affects uterine contraction, which can lead to excessive bleeding.
D) Urinary tract infection: Although urinary retention can increase the risk of urinary tract infections (UTIs) due to incomplete bladder emptying, this is a less immediate and life-threatening concern compared to excessive bleeding. The primary concern in the immediate postpartum period is the potential for hemorrhage from uterine atony, which is worsened by bladder distention.
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