While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a C with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive reflex.

Moro reflex

Babinski reflex

Tonic neck reflex

Rooting reflex

Answer and Explanation

The Correct Answer is A

A.   The described reflex is the Moro reflex, which is a normal startle reflex in newborns.
B.   The Babinski reflex involves the extension of the big toe and fanning of the other toes in response to stroking the sole of the foot.
C. The Tonic neck reflex involves turning the head to one side, with the arm on that side extending and the opposite arm flexing.
D.   The Rooting reflex involves turning the head and opening the mouth in response to cheek or mouth stimulation.

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Correct Answer is A

Explanation

A. Breast milk typically comes in 3 to 5 days postpartum.
B. This timeline is too early for the onset of mature breast milk.
C. This timeline is too late for the onset of mature breast milk.
D. This timeline is too late for the onset of mature breast milk.

A. Assess the client’s uterine fundus. B. Assist the client on a bedpan to urinate. C. Increase the client’s fluid intake. D. Prepare to administer oxytocic medication.

Correct Answer is A

Explanation

A. The priority is to assess the client's uterine fundus to determine if it is well-contracted. Excessive bleeding could be indicative of uterine atony, and prompt assessment is crucial for intervention.
B. Assisting the client on a bedpan to urinate is a secondary intervention. While a distended bladder can contribute to uterine atony, assessing the fundus comes first to determine the cause.
C. Increasing fluid intake is important for postpartum recovery, but it is not the immediate priority in this situation.
D. Preparing to administer oxytocic medication may be necessary if uterine atony is identified during the fundal assessment. However, assessing the fundus comes first to guide appropriate interventions.

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While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a C with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive reflex.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postpartum who asks the nurse when her breast milk will "come in." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?

Correct Answer is A

Explanation

While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a C with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive reflex.

A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the newborn's mouth, which of the following responses should the nurse make?

A nurse is reinforcing teaching about newborn care with a postpartum client. Which of the following statements by the client indicates a need for further teaching?

The nurse is cognizant of which information related to the administration of vitamin K?

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client’s perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

The most serious complication of an infant heelstick is necrotizing osteochondritis resulting from lancet penetration of the bone. What approach should the nurse take when performing the test to prevent this complication?

A nurse is teaching a new mother the best method to store milk and use it later for feeding. She explains that the breast milk should never be thawed or heated in a microwave oven because of the following reasons. Please select all that apply