Nokea
The new mother calls the nurse to her room to show how her baby is "jerking around" when she changes his position. The nurse understands that the baby is exhibiting which normal reflex?
- A. Traction reflex
- B. Babinski reflex
- C. Tonic neck reflex
- D. Moro reflex
Correct Answer: D
Rationale: The Moro reflex (startle reflex) causes the baby to abduct the extremities and fan the fingers with the thumb and index fingers making a "C" shape followed by flexion and adduction of the extremities.
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Why is vitamin K given by injection to the newborn?
- A. Most mothers have a vitamin K deficiency that develops during pregnancy.
- B. Bacteria that synthesize vitamin K are not present in newborns.
- C. Vitamin K prevents the synthesis of prothrombin.
- D. The newborn does not store vitamin K.
Correct Answer: B
Rationale: Newborns are not able to synthesize vitamin K in the colon until they have adequate intestinal flora, therefore, the vitamin K injection is given as a prevention measure against hemorrhage.
Which newborn assessment finding can suggest a chromosomal disorder?
- A. Epstein pearls
- B. Gynecomastia
- C. Babinski reflex
- D. Simian crease
Correct Answer: D
Rationale: A simian crease may indicate a chromosomal disorder.
What is the name of the vaginal discharge that occurs immediately following delivery?
- A. Lochia serosa
- B. Lochia rubra
- C. Lochia palatine
- D. Lochia alba
Correct Answer: B
Rationale: The vaginal discharge that occurs immediately following discharge is known as lochia rubra and is made up mostly of blood. As the placenta heals, the draining turns pink to dark brown in color and is known as lochia serosa. After about 7 days, the discharge turns slight yellow to white and is called lochia alba.
What is the first secretion produced by the breast?
- A. Prolactin
- B. Colostrum
- C. False milk
- D. Whey
Correct Answer: B
Rationale: The first secretion to be produced by the breast is colostrum.
The nurse is caring for a newborn who was circumcised earlier in the day. What should be included in the plan of care?
- A. Administration of a topical anesthetic to the site
- B. Application of ice to stop bleeding
- C. Retraction of any remaining foreskin
- D. Observation for bleeding for the first 12 hours
Correct Answer: D
Rationale: The nurse should assess for bleeding for the first 12 hours following the circumcision. Gentle pressure should be applied to control bleeding. The administration of topical anesthetic and the retraction of the remaining foreskin are not included in the plan of care.