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. Drying the newborn's skin thoroughly helps reduce evaporative heat loss by removing wetness and promoting warmth.
B. Preventing air drafts is important to reduce convective heat loss.
C. Placing the newborn on a warm surface helps prevent conductive heat loss.
D. Maintaining ambient room temperature is important but does not directly address evaporative heat loss.

A. "I wish he had more hair. I don't like the way he looks." B. "He's got my husband's nose, that's for sure." C. "I don't need a baby bath demonstration. I know how to do it." D. "Do you think you could keep him in the nursery for the next feeding so I can get some sleep?"

Correct Answer is A

Explanation

A. Expressing dissatisfaction with the baby's appearance may indicate a lack of immediate bonding.
B. Noting physical features shared with the father suggests recognition and connection.
C. Declining a baby bath demonstration doesn't necessarily indicate a lack of attachment.
D. Requesting nursery care for sleep doesn't necessarily indicate a lack of attachment.

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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 on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?

Correct Answer is A

Explanation

A nurse is caring for a client who is postpartum. The nurse should recognize which of the following statements by the client as an indication of inhibition of parental attachment?

Correct Answer is A

Explanation

A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following client statements indicates to the nurse that further teaching is needed??

A nurse is teaching about crib safety with the parent of a newborn. Which of the following statements by the client indicates understanding of the teaching?

A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago by cesarean section is found to have moist lung sounds. What is the best interpretation of these data?

A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?

A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care?

A nurse is providing teaching about newborn care to a client who is 2 hr postpartum. Which of the following statements by the client indicates a need for further teaching?