Review Nursing Interventions

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Nursing Interventions

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Question 1:

A nurse is assessing a newborn’s reflexes as part of a routine examination.

Which of the following reflexes should the nurse expect to disappear by 3 months of age?

A. Moro B. Palmar grasp C. Rooting D. Tonic neck

Explanation

The rooting reflex is a survival instinct that helps the baby find and latch onto a nipple to feed.This reflex starts when the corner of the baby’s mouth is stroked or touched, and the baby turns his or her head and opens his or her mouth to follow and root in the direction of the stroking.This reflex lasts about 4 months.

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Question 2:

A nurse is educating a new mother about the benefits of skin-to-skin contact with her newborn.

Which of the following statements by the mother indicates an understanding of the teaching? (Select all that apply.)

A. “It will help my baby develop his sucking reflex.” B. “It will keep my baby warm and comfortable.” C. “It will reduce my baby’s risk of infection.” D. “It will enhance my baby’s bonding with me.” E. “It will stimulate my baby’s brain development.”

Explanation

These statements indicate an understanding of the teaching because they reflect the benefits of skin-to-skin contact with the newborn.According to various sources, skin-to-skin contact can help the baby develop his sucking reflex, keep the baby warm and comfortable, enhance the baby’s bonding with the mother, and stimulate the baby’s brain development.

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Question 3:

A nurse is observing a newborn for signs of neonatal neck righting reflex.

The nurse gently turns the newborn’s head to one side and observes the response.

What should the nurse expect to see if the reflex is present?

A. The newborn’s arm and leg on the same side as the head extend, while the opposite side flex. B. The newborn’s arm and leg on the opposite side as the head extend, while the same side flex. C. The newborn’s arm and leg on both sides extend and then flex. D. The newborn’s arm and leg on both sides flex and then extend.

Explanation

the neonatal neck righting reflex is triggered by stretching of the neck muscles when there is rotation of the head or movement of the cervical/neck spine.This reflex is present at birth in a normal full term baby and strongest at about three months of age.

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