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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.
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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.
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 in latent phase of labor for 12 hours, requesting medication to rest
A client in latent phase of labor for the past 12 hours is requesting medication to help her rest.
- A. Fentanyl
- B. Meperidine.
- C. Morphine.
- D. Secobarbital.
- E. Secobarbital.
Correct Answer: A
Rationale: Fentanyl is a fast-acting opioid suitable for pain relief and sedation in labor, with less risk of prolonged effects compared to other options.
Primigravida client in second stage of labor, moaning and screaming, husband requests pain medication
A primigravida client in the second stage of labor has been moaning, screaming, and generally vocal throughout her labor. Her husband is distraught seeing his wife this way and asks the nurse for more pain medication for her. What is the nurse's best response?
- A. Assist the client with breathing and imagery techniques in an attempt to calm her down.
- B. Ask the client to describe the intensity of her pain on a scale of 0 to 10.
- C. Page the obstetrician to evaluate the client's pain, and administer an appropriate increase in her pain medication.
- D. Reassure the first-time father that his wife will be fine, and offer to stay with her while he takes a walk.
Correct Answer: A
Rationale: Assisting with breathing and imagery techniques provides nonpharmacological pain relief and supports the client's coping mechanisms, which is appropriate as vocalizing is a normal way to express pain during labor.
Newborn placed under radiant heat warmer after birth
A nurse places a newborn under a radiant heat warmer after birth. The purpose of this action is to prevent which of the following in the newborn?
- A. Basal metabolic rate reduction.
- B. Brown fat production.
- C. Shivering.
- D. Cold stress.
Correct Answer: D
Rationale: A radiant heat warmer prevents cold stress by maintaining the newborn's body temperature, avoiding complications like hypoxia and hypoglycemia.