A nurse is collecting data from a newborn who was delivered at 40 weeks of gestation. Which of the following is an expected finding when eliciting reflexes from the newborn?
The newborn's legs flex at the knees and hips when pressure is applied to the soles of the newborn's feet.
The newborn closes their eyes and keeps them closed when tapped on the forehead.
The newborn's fingers curl around the nurse's finger when placed in the newborn's palm.
The newborn turns their head away from the stimulus when their cheek is touched.
The Correct Answer is C
Choice A rationale
The newborn's legs flexing at the knees and hips when pressure is applied to the soles indicates the stepping reflex, an expected response.
Choice B rationale
Newborns do not typically keep their eyes closed when tapped on the forehead; this is not an expected reflex response.
Choice C rationale
The palmar grasp reflex, where the newborn's fingers curl around the nurse's finger, is an expected and normal finding in newborns, indicating healthy neurological function.
Choice D rationale
The rooting reflex, where the newborn turns their head when their cheek is touched, is expected and demonstrates feeding readiness and normal neural development. .
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Correct Answer is B
Explanation
Choice A rationale
Chemotherapy is not a standard treatment for a molar pregnancy unless malignancy is suspected or confirmed. It is usually monitored with regular HCG levels and follow-up.
Choice B rationale
Attending a support group is crucial for emotional support and ensuring that the client has access to resources and information about recovery and future pregnancy planning.
Choice C rationale
Home palliative services are not typically required after a molar pregnancy unless there are specific complications that necessitate such care. The focus is generally on monitoring HCG levels and follow-up.
Choice D rationale
An amniocentesis is not needed after a molar pregnancy. Follow-up includes HCG level monitoring to ensure all molar tissue is gone and to watch for malignancy, not amniocentesis.
Correct Answer is B
Explanation
Choice A rationale
Wearing an underwire bra is not recommended for clients with inverted nipples as it can cause discomfort and restrict milk flow. Proper support without constriction is essential.
Choice B rationale
Placing breast shells in the client's bra helps to draw out inverted nipples by applying gentle pressure, making breastfeeding easier. They also protect the nipples from friction and irritation.
Choice C rationale
Providing plastic-lined breast pads may prevent leakage, but they do not address the issue of inverted nipples. Proper nipple preparation is essential for effective breastfeeding.
Choice D rationale
Applying breast cream regularly might keep the skin hydrated, but it does not help to correct the inversion of the nipples. Mechanical aids like breast shells are more effective.