Nokea
Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot?
- A. Babinski
- B. Stepping
- C. Tonic neck
- D. Plantar grasp
Correct Answer: A
Rationale: The correct answer is A: Babinski reflex. This reflex is elicited by stroking the lateral sole of the infant's foot, causing the big toe to extend and the other toes to fan out. This response is normal in infants up to 2 years old. The other choices are incorrect because:
B: Stepping reflex is the automatic movement of the legs when held upright with the feet touching a surface.
C: Tonic neck reflex occurs when an infant turns their head to one side, the arm on that side extends while the opposite arm flexes.
D: Plantar grasp reflex is when pressure is applied to the sole of the foot, causing the toes to curl.
You may also like to solve these questions
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.
The nurse knows that newborns that are high-risk for delayed attachment with their parents/caregivers are at risk for what? Select all that apply.
- A. poor breast-feeding initiation
- B. not bonding with their parents
- C. hard to wake to feed
- D. not feeling happy
Correct Answer: B
Rationale: Delayed attachment can lead to difficulties in breastfeeding initiation and emotional bonding.
The nurse notes swelling in the scrotum of a newborn infant. Transillumination reveals a reddish-yellow reflection. What action by the nurse is best?
- A. Document the findings and reassure the parents.
- B. Elevate the scrotum and apply ice for 20 minutes.
- C. Notify the health-care provider immediately.
- D. Obtain informed consent for emergent surgery.
Correct Answer: A
Rationale: When the nurse assesses a swollen scrotum, it is important to determine that the scrotal sac does not contain entrapped bowel or a mass. Transillumination can determine the presence of a mass when the light directed at the scrotum does not produce a reflection. A reddish-yellow reflection indicates fluid, which will be reabsorbed on its own. The nurse should document the findings and reassure the parents. No further action is needed.
A nurse is providing discharge teaching to parents of a newborn. The baby had no medical problems and is healthy other than having failed an automated auditory brainstem response (AABR) hearing test conducted in the nursery. What information does the nurse provide?
- A. AABR tests are conclusive and the baby is deaf.
- B. Background noise may have interfered with the test.
- C. The babys hearing should be retested within 1 month.
- D. The baby should have another hearing test next week.
Correct Answer: C
Rationale: Babies who fail a hearing screening test at birth should have a follow-up test within a month. The AARB test can be conducted in the presence of background noise. The results are not conclusive (it is a screening device)
A nurse is preparing to discharge an infant who has developmental dysplasia of the hip (DDH). What discharge instruction would be most important?
- A. How to correctly perform Ortolani's maneuver
- B. How to properly use the Pavlik harness
- C. When to return for corrective surgery
- D. Where to take the baby to be fit for corrective shoes
Correct Answer: B
Rationale: A baby with DDH will be placed in a special splint, most often the Pavlik harness, to keep the legs in a position of abduction. The harness is worn continuously for 3-6 months, during which time bone growth helps create a normal hip joint. Ortolani's maneuver is an assessment for DDH. Surgery may be required, but not until it has been determined that bone growth is not creating a normally shaped hip joint. Corrective shoes are not needed.