Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The names of the newborn reflexes are? Select all that apply. (Select All that Apply.)
A. Moro
Moro is a newborn reflex that occurs when the baby is startled by a loud sound or movement. The baby will cry, throw back his or her head, and then pull his or her limbs into the body. This reflex lasts until the baby is about 2 months old.
B. Rooting
Rooting is a newborn reflex that starts when the corner of the baby's mouth is stroked or touched. The baby will turn his or her head and open his or her mouth to follow and root in the direction of the stroking. This helps the baby find the breast or bottle to start feeding. This reflex lasts about 4 months.
C. Gag
Gag is a newborn reflex that prevents the baby from choking on foreign objects. The baby will cough, gag or spit out anything that touches the back of the throat or the roof of the mouth. This reflex is present throughout life.
D. Running
Running is not a newborn reflex. It is a voluntary movement that develops later in childhood.
E. Babinski
Babinski is a newborn reflex that occurs when the sole of the foot is stroked from heel to toe. The baby will fan out and curl up the toes and twist the foot inward. This reflex lasts until the baby is about 12 months old.
F. Stepping
Stepping is a newborn reflex that occurs when the baby is held upright with his or her feet touching a solid surface. The baby will appear to take steps or dance. This reflex lasts about 2 months.
G. Crawling Reflex
The crawling reflex is a developmental milestone observed in infants around 6-8 months of age. It involves the baby moving on their hands and knees, often starting with a belly-crawling motion. Unlike newborn reflexes, this skill is learned and requires muscle coordination and strength.
H. Standing with Support
Standing with support is a developmental milestone typically achieved by infants around 9-12 months. In this skill, the baby pulls themselves up to a standing position while holding onto furniture or a caregiver’s hands. It is a learned behavior reflecting increased muscle strength and balance, distinct from newborn reflexes.
I. Pincer Grasp
The pincer grasp is a fine motor skill that usually develops between 8-12 months. It involves the baby using the thumb and index finger to pick up small objects. This ability is not a reflex but a learned skill that demonstrates improved hand-eye coordination and dexterity.
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Full Explanation
Choice A reason:
Moro is a newborn reflex that occurs when the baby is startled by a loud sound or movement. The baby will cry, throw back his or her head, and then pull his or her limbs into the body. This reflex lasts until the baby is about 2 months old.
Choice B reason:
Rooting is a newborn reflex that starts when the corner of the baby's mouth is stroked or touched. The baby will turn his or her head and open his or her mouth to follow and root in the direction of the stroking. This helps the baby find the breast or bottle to start feeding. This reflex lasts about 4 months.
Choice C reason:
Gag is a newborn reflex that prevents the baby from choking on foreign objects. The baby will cough, gag or spit out anything that touches the back of the throat or the roof of the mouth. This reflex is present throughout life.
Choice D reason:
Running is not a newborn reflex. It is a voluntary movement that develops later in childhood. Choice E reason:
Babinski is a newborn reflex that occurs when the sole of the foot is stroked from heel to toe. The baby will fan out and curl up the toes and twist the foot inward. This reflex lasts until the baby is about 12 months old.
Choice F reason:
Stepping is a newborn reflex that occurs when the baby is held upright with his or her feet touching a solid surface. The baby will appear to take steps or dance. This reflex lasts about 2 months.
Choice G reason:
The crawling reflex is a developmental milestone observed in infants around 6-8 months of age. It involves the baby moving on their hands and knees, often starting with a belly-crawling motion. Unlike newborn reflexes, this skill is learned and requires muscle coordination and strength.
Choice H reason:
Standing with support is a developmental milestone typically achieved by infants around 9-12 months. In this skill, the baby pulls themselves up to a standing position while holding onto furniture or a caregiver’s hands. It is a learned behavior reflecting increased muscle strength and balance, distinct from newborn reflexes.
Choice I reason:
The pincer grasp is a fine motor skill that usually develops between 8-12 months. It involves the baby using the thumb and index finger to pick up small objects. This ability is not a reflex but a learned skill that demonstrates improved hand-eye coordination and dexterity.
Similar Questions
A nurse is caring for a client who is at 36 weeks of gestation and has suspected placenta previa. For which of the following findings should the nurse monitor the client?
A. Intermittent abdominal pain following passage of bloody mucus.
Intermittent abdominal pain following passage of bloody mucus is not a sign of placenta previa, but rather of bloody show, which is a normal occurrence in late pregnancy as the cervix begins to dilate and efface.
B. Abdominal pain with minimal red vaginal bleeding.
Abdominal pain with minimal red vaginal bleeding is not a sign of placenta previa, but rather of abruptio placentae, which is a serious complication where the placenta detaches from the uterine wall before delivery.
C. A large amount of bright red vaginal bleeding without pain.
A large amount of bright red vaginal bleeding without pain is a sign of placenta previa, which is a condition where the placenta covers part or all of the cervical opening. This can cause bleeding when the cervix dilates or contracts, especially in the third trimester. This is a medical emergency that requires immediate attention.
D. Severe abdominal pain with increasing fundal height.
Severe abdominal pain with increasing fundal height is not a sign of placenta previa, but rather of uterine rupture, which is a rare but life-threatening complication where the uterus tears open along the scar line from a previous cesarean delivery or other uterine surgery. This can cause severe bleeding, fetal distress, and shock.
Full Explanation
Choice A reason:
Intermittent abdominal pain following passage of bloody mucus is not a sign of placenta previa, but rather of bloody show, which is a normal occurrence in late pregnancy as the cervix begins to dilate and efface.
Choice B reason:
Abdominal pain with minimal red vaginal bleeding is not a sign of placenta previa, but rather of abruptio placentae, which is a serious complication where the placenta detaches from the uterine wall before delivery.
Choice C reason:
A large amount of bright red vaginal bleeding without pain is a sign of placenta previa, which is a condition where the placenta covers part or all of the cervical opening. This can cause bleeding when the cervix dilates or contracts, especially in the third trimester. This is a medical emergency that requires immediate attention.
Choice D reason:
Severe abdominal pain with increasing fundal height is not a sign of placenta previa, but rather of uterine rupture, which is a rare but life-threatening complication where the uterus tears open along the scar line from a previous cesarean delivery or other uterine surgery. This can cause severe bleeding, fetal distress, and shock.
A patient diagnosed with Iron deficiency has been instructed to eat iron-rich food, what statement indicates understanding by the patient?
A. "I will eat leafy green vegetables.".
Eating leafy green vegetables is a good way to increase iron intake, as they are rich in iron and other nutrients. Iron is needed to produce hemoglobin, the protein that carries oxygen in red blood cells. Iron deficiency anemia occurs when there is not enough iron to make hemoglobin, resulting in low red blood cell count and low oxygen delivery to the tissues. Leafy green vegetables such as broccoli, kale, turnip greens, and collard greens are among the best sources of iron from plants.
B. "I will take calcium supplements.".
Taking calcium supplements is not helpful for iron deficiency anemia, as calcium can interfere with iron absorption. Calcium binds to iron in the intestine and prevents it from being absorbed into the bloodstream. Therefore, calcium supplements should not be taken at the same time as iron supplements or iron-rich foods. Calcium is important for bone health, but it does not affect hemoglobin production or red blood cell count.
C. "I will consume two glasses of prune juice daily.".
Consuming two glasses of prune juice daily is not advisable for iron deficiency anemia, as prune juice has a laxative effect and can cause diarrhea. Diarrhea can lead to dehydration and loss of nutrients, including iron. Prune juice also contains oxalates, which are compounds that can reduce iron absorption by forming insoluble complexes with iron in the intestine. Prune juice does contain some iron, but not enough to compensate for its negative effects on iron status.
D. "I will consume raw sushi.".
Consuming raw sushi is not recommended for iron deficiency anemia, as raw fish can contain parasites or bacteria that can cause infections. Infections can increase inflammation and blood loss, which can worsen iron deficiency anemia. Raw fish also contains phytates, which are substances that can inhibit iron absorption by binding to iron in the intestine. Raw fish does provide some iron, but it is not a reliable or safe source of iron for people with iron deficiency anemia. : Iron deficiency anemia - Diagnosis & treatment - Mayo Clinic. : Iron- Deficiency Anemia - Hematology.org.
Full Explanation
Choice A reason:
Eating leafy green vegetables is a good way to increase iron intake, as they are rich in iron and other nutrients. Iron is needed to produce hemoglobin, the protein that carries oxygen in red blood cells. Iron deficiency anemia occurs when there is not enough iron to make hemoglobin, resulting in low red blood cell count and low oxygen delivery to the tissues.
Leafy green vegetables such as broccoli, kale, turnip greens, and collard greens are among the best sources of iron from plants.
Choice B reason:
Taking calcium supplements is not helpful for iron deficiency anemia, as calcium can interfere with iron absorption. Calcium binds to iron in the intestine and prevents it from being absorbed into the bloodstream. Therefore, calcium supplements should not be taken at the same time as iron supplements or iron-rich foods. Calcium is important for bone health, but it does not affect hemoglobin production or red blood cell count.
Choice C reason:
Consuming two glasses of prune juice daily is not advisable for iron deficiency anemia, as prune juice has a laxative effect and can cause diarrhea. Diarrhea can lead to dehydration and loss of nutrients, including iron. Prune juice also contains oxalates, which are compounds that can reduce iron absorption by forming insoluble complexes with iron in the intestine. Prune juice does contain some iron, but not enough to compensate for its negative effects on iron status.
Choice D reason:
Consuming raw sushi is not recommended for iron deficiency anemia, as raw fish can contain parasites or bacteria that can cause infections. Infections can increase inflammation and blood loss, which can worsen iron deficiency anemia. Raw fish also contains phytates, which are substances that can inhibit iron absorption by binding to iron in the intestine. Raw fish does provide some iron, but it is not a reliable or safe source of iron for people with iron deficiency anemia. : Iron deficiency anemia - Diagnosis & treatment - Mayo Clinic. : Iron- Deficiency Anemia - Hematology.org.
A nurse is caring for a newborn who was delivered by vacuum extraction and has swelling on his head that crosses the suture line. The newborn's mother asks about the swelling on her newborn's head. Which of the following responses should the nurse make?
A. "This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor.".
This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor. This is the correct answer because caput succedaneum is a swelling of the scalp that crosses the suture line and is caused by prolonged pressure on the baby's head during delivery. It can also result from the use of vacuum extraction or forceps. Caput succedaneum is harmless and usually resolves on its own within a few days.
B. "This is erythema toxicum, which is a transient allergic reaction that causes edema in the skin.".
This is erythema toxicum, which is a transient allergic reaction that causes edema in the skin. This is incorrect because erythema toxicum is a common rash that affects newborns, but it does not cause swelling of the scalp or cross the suture line. It appears as red blotches with small white or yellow bumps that can occur anywhere on the body. Erythema toxicum is also harmless and usually disappears within a week.
C. "This is a cephalhematoma, which will resolve on its own in 3 to 5 days.".
This is a cephalhematoma, which will resolve on its own in 3 to 5 days. This is incorrect because cephalhematoma is bleeding under the scalp that does not cross the suture line and is caused by ruptured blood vessels in the scalp. It can also result from the use of vacuum extraction or forceps. Cephalhematoma may take weeks or months to resolve and can increase the risk of jaundice.
D. "This is a Mongolian spot, which is found on many newborns.".
This is a Mongolian spot, which is found on many newborns. This is incorrect because Mongolian spots are bluish-gray patches of skin that are present at birth and are caused by melanocytes (pigment-producing cells) that are trapped in the deeper layers of the skin. They are not related to swelling or pressure on the head and usually fade by age 5.
Full Explanation
Choice A reason:
This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor. This is the correct answer because caput succedaneum is a swelling of the scalp that crosses the suture line and is caused by prolonged pressure on the baby's head during delivery. It can also result from the use of vacuum extraction or forceps. Caput succedaneum is harmless and usually resolves on its own within a few days.
Choice B reason:
This is erythema toxicum, which is a transient allergic reaction that causes edema in the skin. This is incorrect because erythema toxicum is a common rash that affects newborns, but it does not cause swelling of the scalp or cross the suture line. It appears as red blotches with small white or yellow bumps that can occur anywhere on the body. Erythema toxicum is also harmless and usually disappears within a week.
Choice C reason:
This is a cephalhematoma, which will resolve on its own in 3 to 5 days. This is incorrect because cephalhematoma is bleeding under the scalp that does not cross the suture line and is caused by ruptured blood vessels in the scalp. It can also result from the use of vacuum extraction or forceps. Cephalhematoma may take weeks or months to resolve and can increase the risk of jaundice.
Choice D reason:
This is a Mongolian spot, which is found on many newborns. This is incorrect because Mongolian spots are bluish-gray patches of skin that are present at birth and are caused by melanocytes (pigment-producing cells) that are trapped in the deeper layers of the skin. They are not related to swelling or pressure on the head and usually fade by age 5.