Nokea
The nurse is aware that a full-term infant is born with which reflexes?
- A. Blinking
- B. Sneezing
- C. Gagging
- D. Sucking
- E. Pincer grasping
Correct Answer: A,B,C,D
Rationale: Blinking, sneezing, gagging, and sucking reflexes are present in the full-term newborn. Pincer grasp develops between 8 and 12 months.
You may also like to solve these questions
Which finding needs to be reported promptly to the child's pediatrician?
- A. The hands and feet feel cooler than the rest of the body.
- B. Skin is peeling on several parts of the infant's body.
- C. There is a small pink patch on the left eyelid and one on the neck.
- D. Today, the infant's skin has a yellowish tinge.
Correct Answer: D
Rationale: Physiological jaundice becomes evident between the second and third days of life and requires evaluation if observed.
What action does the nurse implement to protect newborns from infection while in the nursery?
- A. Keep the newborn dressed warmly.
- B. Adjust room temperature between 23.8?°C (75?°F) and 26.6?°C (80?°F).
- C. Wash hands before touching each infant.
- D. Wear a disposable gown when giving infant care.
Correct Answer: C
Rationale: Hand washing is the most reliable precaution to prevent infection between handling different babies.
What is the most appropriate nursing response to this mother?
- A. Tell me how many hours per day your baby sleeps.'
- B. It is normal for newborns to sleep most of the day.'
- C. Newborns generally sleep 12 to 15 hours per day.'
- D. You will find as the baby gets older, he sleeps less.'
Correct Answer: A
Rationale: The nurse should first clarify what the mother means by 'too much' sleep to provide accurate information and address concerns.
Which interventions would be included in the nursing care of the newly circumcised infant?
- A. Wash penis with warm water.
- B. Wipe with alcohol swab.
- C. Gently remove the yellow crust formation.
- D. Apply diaper loosely.
- E. Dress with simple bandage.
Correct Answer: A,D
Rationale: Postcircumcision care includes washing with warm water and diapering loosely, while avoiding alcohol wipes and leaving the yellow crust in place.
What is the most appropriate intervention by the nurse?
- A. Do nothing because this is a normal occurrence.
- B. Report the discrepancy to the pediatrician immediately.
- C. Decrease the interval between the infant's feedings.
- D. Try feeding the infant a different type of formula.
Correct Answer: A
Rationale: It is typical for newborns to lose 5% to 10% of their birth weight in the first 3 to 4 days of life, requiring no change in the plan of care.