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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?

A.

The newborn's legs flex at the knees and hips when pressure is applied to the soles of the newborn's feet.

B.

The newborn closes their eyes and keeps them closed when tapped on the forehead.

C.

The newborn's fingers curl around the nurse's finger when placed in the newborn's palm.

D.

The newborn turns their head away from the stimulus when their cheek is touched.

Answer and Explanation

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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View Related questions

Correct Answer is ["C","E"]

Explanation

Choice A rationale

Douching is generally not recommended, especially during pregnancy, because it can disrupt the natural balance of bacteria in the vagina, potentially leading to infections or other complications.

Choice B rationale

Avoiding urination at bedtime is not advisable, as holding in urine can increase the risk of urinary tract infections (UTIs). Frequent urination is a good practice to help prevent and manage UTIs.

Choice C rationale

Wearing cotton-crotch underwear is recommended because cotton is breathable and helps to keep the genital area dry, reducing the risk of infections and irritation.

Choice D rationale

Eliminating yogurt products from the diet is not necessary; in fact, yogurt contains probiotics that can be beneficial for maintaining a healthy balance of bacteria in the gut and vaginal area.

Choice E rationale

Refraining from taking bubble baths is advised, as the chemicals in bubble bath products can irritate the urethra and increase the risk of UTIs.

Correct Answer is D

Explanation

Choice A rationale

Remaining in the sitz bath for only 10 minutes might not provide enough relief for a postpartum client with an episiotomy and hemorrhoids. Extended periods in a sitz bath can help reduce pain and promote healing.

Choice B rationale

Using numbing spray before cleansing is helpful for pain management, but it is not as beneficial as other methods for reducing inflammation and promoting healing.

Choice C rationale

Placing a heat pack to the area several times a day can help with pain but might not be as effective as other options in reducing swelling and promoting healing of hemorrhoids and episiotomy sites.

Choice D rationale

Applying witch hazel pads after urination helps reduce swelling, provides soothing relief, and promotes healing for both hemorrhoids and episiotomy sites. Witch hazel has natural astringent properties that are beneficial for postpartum perineal care.

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