Nokea
The nurse is about to elicit the Moro reflex. Which of the following responses should the nurse expect to see?
- A. When the cheek of the baby is touched
- B. the newborn turns toward the side that is touched.
- C. When the lateral aspect of the sole of the baby's foot is stroked
- D. the toes extend and fan outward.
Correct Answer: C
Rationale: Moro reflex involves extension of arms and flexion of knees in response to a sudden stimulus.
You may also like to solve these questions
A client, who is 2 weeks postpartum, calls her obstetrician's nurse and states that she has had a whitish discharge for 1 week but today she is"bleeding and saturating a pad about every 1/2 hour."Which of the following is an appropriate response by the nurse?
- A. That is normal. You are starting to menstruate again.
- B. You should stay on complete bed rest until the bleeding subsides.
- C. Pushing during a bowel movement may have loosened your stitches.
- D. The physician should see you. Please go to the emergency department.
Correct Answer: D
Rationale: Heavy bleeding postpartum requires immediate medical attention.
A nurse is advising a mother of a neonate being discharged from the hospital regarding car seat safety. Which of the following should be included in the teaching plan? Select all that apply.
- A. Place the baby's car seat in the front passenger seat.
- B. Position the car seat rear facing until the baby reaches two years of age.
- C. Attach the car seat to the car at 2 latch points at the base of the car seat.
- D. Check that the installed car seat moves no more than 1 inch side to side or front to back.
Correct Answer: B
Rationale: Rear-facing positioning and secure installation are critical for safety.
The mother notes that her baby has a 'bulge' on the back of one side of the head. She calls the nurse into the room to ask what the bulge is. The nurse notes that the bulge covers the right parietal bone but does not cross the suture lines. The nurse explains to the mother that the bulge results from which of the following?
- A. Molding of the baby's skull so that the baby could fit through her pelvis.
- B. Swelling of the tissues of the baby's head from the pressure of her pushing.
- C. The position that the baby took in her pelvis during the last trimester of her pregnancy.
- D. Small blood vessels that broke under the baby's scalp during birth.
Correct Answer: A
Rationale: Molding occurs due to passage through the birth canal.
A client has given birth to a baby girl with a visible birth defect. Which of the following maternal responses would lead the nurse to suspect poor mother-infant bonding?
- A. The mother states,"I'm so tired. Please feed the baby in the nursery for me."
- B. The mother states,"Her eyes look like mine, but her chin is her Dad's."
- C. The mother says,"We have decided to name her Sarah after my mother."
- D. The mother says,"I breastfed her. I still need help swaddling her, though."
Correct Answer: A
Rationale: Avoidance of infant care suggests bonding issues.
A 4-day-old breastfeeding neonate whose birth weight was 2,678 grams has lost 100 grams since the cesarean birth. Which of the following actions should the nurse take?
- A. Nothing because this is an acceptable weight loss.
- B. Advise the mother to supplement feedings with formula.
- C. Notify the neonatologist of the excessive weight loss.
- D. Give the baby dextrose water between breast feedings.
Correct Answer: A
Rationale: Weight loss within 5% is normal.