A nurse reads in the chart that a baby has a positive crossed extension reflex and asks a more experienced nurse to demonstrate this assessment. How does the nurse perform the assessment?

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Nursing Care of the Newborn and Family Questions

Question 1 of 5

A nurse reads in the chart that a baby has a positive crossed extension reflex and asks a more experienced nurse to demonstrate this assessment. How does the nurse perform the assessment?

Correct Answer: A

Rationale: A positive crossed extension reflex occurs when the infant is supine and one foot is stimulated. The infant should flex, adduct, and then extend the opposite leg. Tapping the forehead is part of the glabellar reflex assessment. The crawling reflex is present when the infant attempts to crawl while prone. The Galant reflex (or trunk incurvation reflex) is assessed with the infant in a prone position. Stroke one side of the vertebral column and watch the baby's buttocks curve toward the side where the stimulation occurred.

Question 2 of 5

A full-term newborn has been delivered by a physician after a lengthy labor and delivery. The newborn has poor tone, minimal respiratory effort, and central cyanosis. The cord is cut, and the patient is placed in an infant warmer. What data does the nurse need to notice that are clinically significant? Select all that apply.

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 3 of 5

Of the three fetal shunts, which one moves fetal blood from the lungs through the right atrium to the left atrium?

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 4 of 5

A newborn at 20 minutes of age has an axillary temperature of 36° C (96.8° F). What intervention should the nurse perform?

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 5 of 5

The nurse is caring for a neonate born at 36 weeks, 2 days by primary cesarean birth and weighing 6 pounds, 4 ounces. The infant cried at delivery, had flexion in all extremities, had a heart rate of 135, had acrocyanosis in hands and feet, and was pale. The infant was placed skin-to-skin with the birthing person and has been latching and cuddling for the past 15 minutes. At 45 minutes, the neonate is found grunting and cool to the touch. What are the nurse’s next steps?

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

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