Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a C with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive reflex.
A. Moro reflex
The described reflex is the Moro reflex, which is a normal startle reflex in newborns.
B. Babinski reflex
The Babinski reflex involves the extension of the big toe and fanning of the other toes in response to stroking the sole of the foot.
C. Tonic neck reflex
The Tonic neck reflex involves turning the head to one side, with the arm on that side extending and the opposite arm flexing.
D. Rooting reflex
The Rooting reflex involves turning the head and opening the mouth in response to cheek or mouth stimulation.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Maternal Newborn Proctored Exam 3 Reno 2 2020. Take the full exam now
Full Explanation
A. The described reflex is the Moro reflex, which is a normal startle reflex in newborns.
B. The Babinski reflex involves the extension of the big toe and fanning of the other toes in response to stroking the sole of the foot.
C. The Tonic neck reflex involves turning the head to one side, with the arm on that side extending and the opposite arm flexing.
D. The Rooting reflex involves turning the head and opening the mouth in response to cheek or mouth stimulation.
Similar Questions
A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?
A. Encourage the client to perform Kegel exercises.
Kegel exercises are not indicated for addressing a boggy uterus; emptying the bladder is a more appropriate intervention.
B. Encourage the client to move to the left lateral position.
Moving to the left lateral position may help, but the primary concern is a full bladder contributing to uterine displacement.
C. Ask the client to rate her pain.
Pain assessment is important but does not directly address the issue of a boggy uterus and displacement.
D. Encourage the client to empty bladder by voiding
Encouraging the client to empty the bladder by voiding is essential, as a full bladder can displace the uterus and contribute to uterine atony.
Full Explanation
A. Kegel exercises are not indicated for addressing a boggy uterus; emptying the bladder is a more appropriate intervention.
B. Moving to the left lateral position may help, but the primary concern is a full bladder contributing to uterine displacement.
C. Pain assessment is important but does not directly address the issue of a boggy uterus and displacement.
D. Encouraging the client to empty the bladder by voiding is essential, as a full bladder can displace the uterus and contribute to uterine atony.
Which hormone remains elevated in the immediate postpartum period of the breastfeeding women?
A. Prolactin
Prolactin remains elevated in the immediate postpartum period of breastfeeding women to stimulate milk production.
B. Progestrone
Progesterone levels decrease rapidly after childbirth.
C. Estrogen
Estrogen levels decrease in the postpartum period, particularly during breastfeeding.
D. Human Placental Lactogen
Human Placental Lactogen (HPL) levels decrease after childbirth.
Full Explanation
A. Prolactin remains elevated in the immediate postpartum period of breastfeeding women to stimulate milk production.
B. Progesterone levels decrease rapidly after childbirth.
C. Estrogen levels decrease in the postpartum period, particularly during breastfeeding.
D. Human Placental Lactogen (HPL) levels decrease after childbirth.
A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client’s perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?
A. Document the findings and continue to monitor the client.
The presence of lochia rubra with small clots in the immediate postpartum period is expected. The firm and midline fundus indicates appropriate uterine contraction. Continued monitoring is appropriate.
B. Encourage the client to empty her bladder.
Encouraging the client to empty her bladder is a valid intervention, but it is not the priority in this situation.
C. Increase the frequency of fundal massage.
Increasing the frequency of fundal massage is unnecessary, as the fundus is already firm.
D. Notify the client’s provider.
Notifying the provider is not necessary based on the described findings, as they are within the expected range.
Full Explanation
A. The presence of lochia rubra with small clots in the immediate postpartum period is expected. The firm and midline fundus indicates appropriate uterine contraction. Continued monitoring is appropriate.
B. Encouraging the client to empty her bladder is a valid intervention, but it is not the priority in this situation.
C. Increasing the frequency of fundal massage is unnecessary, as the fundus is already firm.
D. Notifying the provider is not necessary based on the described findings, as they are within the expected range.