When the newborn's crib was moved suddenly, the nurse noticed that his legs flexed and the arms fanned out, and then both came back toward the midline. The nurse would interpret this behavior as:

The Moro reflex was elicited.

This is abnormal for a full-term infant.

There may be an abnormality in the musculoskeletal system.

The full-term infant should not react to sudden movement.

Answer and Explanation

The Correct Answer is A

The Moro reflex was elicited. This is because the Moro reflex is a normal newborn reflex that occurs when the baby is startled by a loud noise or a sudden movement. The baby responds by extending the arms and legs, opening the hands, and then bringing the arms and legs back to the chest.

The Moro reflex is present at birth and disappears by 3 to 6 months of age.

Choice B is wrong because this is not abnormal for a full-term infant. The Moro reflex is a sign of a healthy nervous system and brain development.

Choice C is wrong because there is no evidence of an abnormality in the musculoskeletal system. The Moro reflex does not indicate any problems with the bones or muscles of the baby.

Choice D is wrong because the full-term infant should react to sudden movement. The Moro reflex is a protective response that helps the baby cling to the mother in case of danger.

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Correct Answer is D

Explanation

Rooting. The rooting reflex is a primitive neonatal reflex that helps the baby find the breast or bottle to start feeding. When the corner of the baby's mouth is stroked or touched, the baby will turn his or her head and open his or her mouth to follow and root in the direction of the stroking. This reflex lasts about 4 months.

Choice A. Sucking is not the correct answer because it is a different reflex that starts when the roof of the baby's mouth is touched, and it does not help the baby find the breast or bottle.

Choice B. Grasp is not the correct answer because it is a reflex that causes the baby to close his or her fingers in a grasp when the palm of the hand is stroked, and it has nothing to do with breastfeeding.

Choice C. Tonic neck is not the correct answer because it is a reflex that causes the baby to assume a "fencing" position when the head is turned to one side, and it also has nothing to do with breastfeeding.

A. Monitor the newborn's blood glucose level hourly. B. Apply lotion to the newborn's skin twice per day. C. Encourage the newborn to breastfeed every 2 hr. D. Maintain the newborn in a prone position.

Correct Answer is C

Explanation

Encourage the newborn to breastfeed every 2 hr. This is because breastfeeding helps the newborn to excrete bilirubin through stool and urine. Breastfeeding also prevents dehydration, which can worsen jaundice. The nurse should also monitor the newborn’s weight, hydration status, and bilirubin levels during phototherapy.

Choice A is wrong because monitoring the newborn’s blood glucose level hourly is not necessary for phototherapy.

Choice B is wrong because applying lotion to the newborn’s skin twice per day can interfere with the effectiveness of phototherapy and increase the risk of skin irritation.

Choice D is wrong because maintaining the newborn in a prone position can increase the risk of sudden infant death syndrome (SIDS) and limit the exposure of skin to light.

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When the newborn's crib was moved suddenly, the nurse noticed that his legs flexed and the arms fanned out, and then both came back toward the midline. The nurse would interpret this behavior as:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A first-time mother reports that she is experiencing difficulty breastfeeding her newborn. The neonatal reflex that the nurse would teach the mother to elicit, in order to facilitate breastfeeding is:

Correct Answer is D

Explanation

A nurse is updating the plan of care for a newborn who is undergoing phototherapy. Which of the following actions should the nurse include in the plan?

Correct Answer is C

Explanation

A nurse is caring for a client who is experiencing shaking chills during the immediate postpartum period. Which of the following actions should the nurse take?

The first sign of hypovolemic shock from postpartum hemorrhage is likely to be:

A nurse is caring for a postpartum client who saturates a perineal pad in 10 minutes. Which of the following actions should the nurse take first?

Five days after a spontaneous vaginal delivery, a woman comes to the emergency room because she has a fever and persistent cramping. The nurse recognizes that the cause of these signs and symptoms may be:

The nurse is visiting a new mother who has been home with a new infant for 4 days. Which observation indicates that the mother's home environment was inadequately assessed prior to being discharged from the hospital?

A new mother of a newborn girl calls the clinic in a panic, concerned about the blood-tinged soiled diaper. What is the best response from the nurse?

A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client's perineal pad. Which of the following actions should the nurse take first?

A nurse is teaching a new mother about signs of effective breastfeeding of her newborn. Which of the following information should the nurse include in the teaching?