Author Question: When assessing a newborn's reflexes, the nurse strokes the newborn's cheek and the newborn turns ... (Read 155 times)

gonzo233 · **on:** Jun 27, 2018

When assessing a newborn's reflexes, the nurse strokes the newborn's cheek and the newborn turns toward the side that was stroked and begins sucking. The nurse documents which reflex as being positive?

A) Palmar grasp reflex
B) Tonic neck reflex
C) Moro reflex
D) Rooting reflex

Question 2

A pregnant patient in labor is having contractions 2 minutes apart but rarely over 50 mmHg in strength; the resting tone is high, 20 to 25 mmHg. The patient asks what can be done to make contractions more effective.

What should the nurse respond to the patient? A) Rest because contractions are hypertonic.
B) Receive oxytocin to strengthen contractions.
C) Hypotonic contractions of this kind will strengthen by themselves.
D) Walking around will make the contractions more regular.

aadams68 · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

D
Feedback:
The rooting reflex is elicited by stroking the newborn's cheek. The newborn should turn toward the side that was stroked and should begin to make sucking movements. The palmar grasp reflex is elicited by placing a finger on the newborn's open palm. The baby's hand will close around the finger. Attempting to remove the finger causes the grip to tighten. The tonic neck reflex is elicited by having the newborn lie on the back and turning the head to one side. The arm toward which the baby is facing should extend straight away from the body with the hand partially open, whereas the arm on the side away from the face is flexed and the fist is clenched tightly. Reversing the direction to which the face is turned reverses the position. The Moro reflex is elicited by placing the newborn on his or her back, supporting the upper body weight of the supine newborn by the arms using a lifting motion without lifting the newborn off the surface. The arms are released suddenly and the newborn will throw the arms outward and flex the knees and then the arms return to the chest. The fingers also spread to form a C.

Answer to Question 2

A
Feedback:
A danger of hypertonic contractions is that the lack of relaxation between contractions may not allow optimal uterine artery filling; this can lead to fetal anoxia early in the latent phase of labor. The best intervention is to encourage the patient to rest between contractions. Oxytocin will not help strengthen hypertonic contractions. Walking will not help make the contractions more regular. These are hypertonic and not hypotonic contractions.