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Newborn reflex observation
What reflex is elicited: Fanning of toes when stroking lateral edge of baby's foot?
- A. Babinski's Reflex.
- B. Stepping Reflex.
- C. Moro reflex.
- D. Plantar Grasp reflex.
Correct Answer: A
Rationale: Babinski's Reflex is elicited by fanning of the toes when the lateral edge of the foot is stroked, normal in infants up to 2 years.
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Newborn boy, 1 minute after birth, heart rate 138 bpm, vigorous crying, spontaneous movement, pink skin with bluish hands and feet
Erin gives birth to a boy. The nurse notes the following on the baby at 1 minute: heart rate is 138 bpm, loud vigorous crying, spontaneous movement and flexion of the extremities, and pink skin color except for a bluish color of the hands and feet. What Apgar score will be assigned to the baby?
- A. 7
- B. 8
- C. 9
- D. 10
Correct Answer: B
Rationale: The baby scores 2 for heart rate (>100 bpm), 2 for respiratory effort (vigorous crying), 2 for muscle tone (spontaneous movement), 2 for reflex irritability (crying), and 1 for color (acrocyanosis), totaling an Apgar score of 8.
Woman received 50 mcg fentanyl intravenously 1 hour before delivery
A woman received 50 mcg of fentanyl intravenously 1 hour before delivery. What drug should the nurse have readily available?
- A. Nalbuphine (Nubain).
- B. Naloxone (Narcan).
- C. Butorphanol (Stadol).
- D. Promethazine (Phenergan).
Correct Answer: B
Rationale: Naloxone (Narcan) reverses opioid effects like fentanyl, critical for addressing potential respiratory depression in the newborn.
Client 2 hours postpartum, vaginal birth
A nurse is caring for a client who is 2 hours postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?
- A. Client report of frequent uterine contractions.
- B. Fundus palpable to right of midline.
- C. Less than 2.5 cm of rubra lochia on perineal pad.
- D. Client report of increased thirst.
Correct Answer: B
Rationale: A fundus palpable to the right of midline suggests a distended bladder, which can displace the uterus from its normal position.
Newborn, signs of diaphoresis, jitteriness, lethargy
A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take?
- A. Obtain blood glucose by heel stick.
- B. Initiate phototherapy.
- C. Monitor the newborn's blood pressure.
- D. Place the newborn in a radiant warmer.
Correct Answer: A
Rationale: These symptoms suggest hypoglycemia, and obtaining a blood glucose level via heel stick is the priority to confirm and guide treatment.
Newborn reflex observation
Which newborn reflex elicits the following reaction: Head turns to one side - the way the head is facing, the arm/leg is stretched out while the other is bent?
- A. Tonic neck reflex.
- B. Moro reflex.
- C. Startled reflex.
- D. Babinski reflex.
Correct Answer: A
Rationale: The tonic neck reflex, also called the fencing posture, occurs when a baby's head is turned to one side, causing the arm and leg on that side to stretch out and the opposite side to bend, matching the described reaction.