Nokea
When the newborn's crib was moved suddenly, the nurse noticed that his legs flexed and arms fanned out, and then both came back toward the midline. How would the nurse interpret this behavior?
- A. The Moro reflex
- B. The grasp reflex
- C. An abnormality of the musculoskeletal system
- D. A neurological abnormality
Correct Answer: A
Rationale: The Moro reflex is a normal neonatal reflex elicited when the infant's crib is jarred, causing the infant to draw the legs up, fan the arms, and then bring the arms to the midline in an embrace position.
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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.
What noninvasive forms of pain relief might a nurse implement with a newborn?
- A. Swaddling
- B. Rocking
- C. Offering a pacifier
- D. Distraction
- E. Cuddling
Correct Answer: A,B,C,E
Rationale: Swaddling, rocking, nonnutritive sucking, and cuddling are effective noninvasive pain remedies for newborns. Distraction is not reliable for infants.
What information will the nurse provide when educating this patient on alendronate (Fosamax)?
- A. Drink 8 oz. of water following dosage.
- B. Lay down for 30 minutes after taking.
- C. This medication has no known side effects.
- D. Avoid weight-bearing exercises.
Correct Answer: A
Rationale: Alendronate (Fosamax) may cause esophageal and gastric irritation. The patient should drink 8 ounces of plain water and sit upright for 30 minutes after taking the drug and before eating. Weight-bearing exercises are advisable, and high-impact exercises should be avoided.
A first-time mother reports that she is experiencing difficulty breastfeeding her newborn. Which neonatal reflex would the nurse teach the mother to elicit to facilitate breastfeeding?
- A. Sucking
- B. Rooting
- C. Grasping
- D. Tonic neck
Correct Answer: B
Rationale: The rooting reflex causes the infant's head to turn in the direction of anything that touches the cheek in anticipation of food, aiding breastfeeding.
The nurse reminds new parents that newborns must be protected from environments that are too cold or too hot because of which aspects of their physiology?
- A. Very little subcutaneous fat
- B. Low metabolic rates
- C. Ineffective sweat glands
- D. Small fluid reserves
- E. Low red blood cell counts
Correct Answer: A,C
Rationale: Newborns have very little subcutaneous fat and ineffective sweat glands, making them susceptible to thermal stress.