Nokea
The nurse is assessing an infant's extrusion reflex. To perform this correctly, what steps does the nurse take?
- A. Place a small object in the infant's hand.
- B. Stroke the side of the infant's cheek.
- C. Touch the tip of the infant's tongue.
- D. Turn the infant's head to one side.
Correct Answer: C
Rationale: The extrusion reflex is elicited by touching the tip of the infant's tongue. The tongue should protrude outward. Palmar grasp is detected by placing a small object in the infant's hand. Stroking the side of the cheek should result in the rooting reflex. Turning the head and watching the position of the extremities is part of the tonic neck or fencing reflex.
You may also like to solve these questions
How can the nurse caring for a patient with a neonatal loss practice self-care?
- A. Refrain from discussing her feelings at work.
- B. Understand that depression is normal after neonatal loss.
- C. Take off work for a week.
- D. Debrief with manager and colleagues.
Correct Answer: D
Rationale: Debriefing with colleagues and managers allows for emotional processing and support, which is crucial after a neonatal loss. Suppressing emotions or taking prolonged leave may hinder recovery and professional functioning.
The newborn nursery nurse knows that infant behavior is best assessed by which of the following?
- A. Ease of learning to nurse
- B. Length of sleeping periods
- C. Presence of reflex activity
- D. Response to stimulation
Correct Answer: D
Rationale: Assessing a baby's response to stimulation is a vital part of a behavioral assessment. The other assessments are not really related, although a jittery, overstimulated baby who does not sleep well may need a quieter environment and more gentle handling.
The nurse is explaining to a mother that her newborn's blood test indicates a high level of unconjugated bilirubin, which causes jaundice. Which information doesn't the nurse present to the mother?
- A. The blood test does not indicate a pathological disease.
- B. The newborn's liver converts bilirubin to a water-soluble substance.
- C. An abundance of RBCs and RBC short life span contributes to the condition.
- D. The newborn's condition is also referred to as hyperbilirubinemia.
Correct Answer: D
Rationale: The correct answer is D because the nurse does not mention the term "hyperbilirubinemia" to the mother. Instead, the nurse focuses on explaining the high level of unconjugated bilirubin causing jaundice.
A: The nurse likely mentioned that the blood test does not indicate a pathological disease to reassure the mother that jaundice is a common condition in newborns.
B: The nurse would have explained that the newborn's liver converts bilirubin to a water-soluble substance as part of the discussion on how bilirubin is processed in the body.
C: An abundance of RBCs and their short lifespan contributing to jaundice would be relevant information that the nurse would provide to explain the underlying causes of the condition.
Which baby is at highest risk of skin infection upon discharge?
- A. Newborn with scabs forming over heels where blood has been drawn
- B. Newborn with a new circumcision
- C. Newborn with jaundice
- D. Newborn with milia
Correct Answer: B
Rationale: The correct answer is B, a newborn with a new circumcision, as this procedure involves an incision, making the baby more susceptible to skin infections. Circumcision wounds need proper care to prevent infection.
Choice A is incorrect because scabs forming over heels where blood has been drawn do not necessarily indicate a higher risk of skin infection. Choice C, a newborn with jaundice, is incorrect as jaundice affects the liver and does not directly increase the risk of skin infection. Choice D, a newborn with milia, is incorrect because milia are harmless and do not increase the risk of skin infection.
The nurse manager is planning a debriefing for several of the nurses after an IPFD. What should the manager expect?
- A. The nurses will need to discuss fault in order to alleviate feelings of guilt.
- B. During the debriefing, some nurses will complain of physical tension, headache, and insomnia.
- C. The nurse caring for the patient will need to defend herself to the health-care provider.
- D. The charge nurse will discuss the nurse’s documentation to prevent a lawsuit.
Correct Answer: B
Rationale: Debriefing sessions often reveal stress-related symptoms such as physical tension, headaches, and insomnia among healthcare providers following traumatic events like IPFD. Focusing on blame or legal concerns detracts from the emotional processing necessary during these sessions.