Review Nursing Interventions

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Nursing Interventions

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Total Questions : 3

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Question 1:

A nurse is assessing a newborn’s reflexes as part of a routine examination.

Which of the following reflexes should the nurse expect to disappear by 3 months of age?

A. Moro B. Palmar grasp C. Rooting D. Tonic neck

Answer and Explanation

Choice A:

Moro reflex is a protective response to a sudden movement or a loud noise, and it lasts until the baby is about 2 months old.

Choice B:

Palmar grasp reflex is a response to stroking the palm of the baby’s hand, causing the baby to close his or her fingers in a grasp, and it lasts until the baby is about 5 to 6 months old.

Choice C:

The rooting reflex is a survival instinct that helps the baby find and latch onto a nipple to feed.This reflex starts when the corner of the baby’s mouth is stroked or touched, and the baby turns his or her head and opens his or her mouth to follow and root in the direction of the stroking.This reflex lasts about 4 months.

Choice D:

Tonic neck reflex is a posture that occurs when the baby’s head is turned to one side, causing the arm on that side to stretch out and the opposite arm to bend up at the elbow, and it lasts until the baby is about 5 to 7 months old.

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Question 2:

A nurse is educating a new mother about the benefits of skin-to-skin contact with her newborn.

Which of the following statements by the mother indicates an understanding of the teaching? (Select all that apply.)

A. “It will help my baby develop his sucking reflex.” B. “It will keep my baby warm and comfortable.” C. “It will reduce my baby’s risk of infection.” D. “It will enhance my baby’s bonding with me.” E. “It will stimulate my baby’s brain development.”

Answer and Explanation

Choice A:

Choice B:

Choice C:

skin-to-skin contact does not reduce the baby’s risk of infection. On the contrary, it may increase the colonization of the baby’s skin with the mother’s friendly bacteria, which can provide protection against infection

Choice D:

Choice E:

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Question 3:

A nurse is observing a newborn for signs of neonatal neck righting reflex.

The nurse gently turns the newborn’s head to one side and observes the response.

What should the nurse expect to see if the reflex is present?

A. The newborn’s arm and leg on the same side as the head extend, while the opposite side flex. B. The newborn’s arm and leg on the opposite side as the head extend, while the same side flex. C. The newborn’s arm and leg on both sides extend and then flex. D. The newborn’s arm and leg on both sides flex and then extend.

Answer and Explanation

Choice A:

the neonatal neck righting reflex is triggered by stretching of the neck muscles when there is rotation of the head or movement of the cervical/neck spine.This reflex is present at birth in a normal full term baby and strongest at about three months of age.

Choice B:

it describes the tonic neck reflex, which is often called the “fencing” reflex because of the position of the hands.This reflex lasts until the baby is about 5 to 7 months old.

Choice C:

it describes the Moro reflex, which is often called a startle reflex.

It usually occurs when a baby is startled by a loud sound or movement.In response to the sound, the baby throws back his or her head, extends out his or her arms and legs, cries, then pulls the arms and legs back in.This reflex lasts until the baby is about 2 months old.

Choice D:

it does not describe any known newborn reflex.

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Nursing Interventions

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