The nurse is assessing an infant's extrusion reflex. To perform this correctly, what steps does the nurse take?

Correct Answer: C

Rationale: The extrusion reflex is elicited by touching the tip of the infant's tongue. The tongue should protrude outward. Palmar grasp is detected by placing a small object in the infant's hand. Stroking the side of the cheek should result in the rooting reflex. Turning the head and watching the position of the extremities is part of the tonic neck or fencing reflex.

Correct Answer: D

Rationale: In understanding the difference in muscle tone between preterm and full-term newborns in pharmacology, it is crucial to grasp the developmental stages of fetal growth and the impact on neuromuscular maturity. The correct answer, D) flaccid, is indicative of the decreased muscle tone often seen in preterm newborns due to their limited time for in utero development. Preterm infants have immature nervous systems, leading to hypotonia or low muscle tone, which manifests as a lack of resistance to passive movement. Option A) firm is incorrect because firm muscle tone is typically associated with hypertonia, which is not a characteristic of preterm newborns. Option B) abnormal is too vague and does not specifically address the issue of muscle tone in preterm infants. Option C) normal is incorrect as preterm newborns do not exhibit normal muscle tone compared to full-term newborns. Educationally, this question highlights the importance of understanding the variations in neuromuscular development between preterm and full-term infants. Nurses caring for newborns need to recognize the implications of decreased muscle tone in preterm infants, as it can impact their ability to feed, maintain body temperature, and reach developmental milestones. This knowledge is essential for providing appropriate care and support to this vulnerable population.

Correct Answer: A

Rationale: Transient tachypnea of the newborn (TTN) is a common respiratory issue in neonates. The correct answer is A) failure to clear lung fluid by the usual mechanism. During birth, the normal process of clearing lung fluid is disrupted, leading to retention of fluid in the lungs and subsequent tachypnea. This condition usually resolves within a few days as the infant's lungs clear the fluid on their own. Option B) failure of the patent ductus arteriosus to close is not related to TTN. The patent ductus arteriosus is a blood vessel in the heart that shunts blood away from the lungs before birth but should close shortly after birth. Option C) insufficient surfactant production is more commonly associated with respiratory distress syndrome (RDS) rather than TTN. Surfactant is a substance that helps keep the lungs inflated and facilitates gas exchange. Option D) aspiration of meconium during birth can lead to meconium aspiration syndrome, which is a different respiratory condition from TTN. Meconium aspiration can cause airway obstruction and inflammation in the lungs. Educationally, understanding the pathophysiology of TTN is crucial for nurses caring for newborns. Recognizing the signs and symptoms of TTN and differentiating it from other neonatal respiratory conditions is essential for providing appropriate care and interventions to support the infant's respiratory function.

Correct Answer: C

Rationale: In fetal circulation, the connection between the systemic aorta, pulmonary blood flow, and pulmonary artery is maintained by the ductus arteriosus. This shunt allows blood to bypass the fetal lungs, as they are non-functional in utero, and directs the oxygenated blood from the placenta to the systemic circulation. Option A) ductus venosus, is a shunt in fetal circulation that allows oxygenated blood from the placenta to bypass the liver and flow directly to the inferior vena cava. Option B) foramen ovale, is a shunt between the right and left atria of the heart that allows most of the blood to flow from the right atrium to the left atrium, bypassing the pulmonary circulation. Option D) foramen venosus is not a recognized fetal shunt in human anatomy. Understanding fetal circulation is crucial for healthcare professionals, especially nurses caring for newborns. Knowledge of these shunts helps in identifying and managing congenital heart defects in newborns. It is essential for nurses to understand the normal fetal circulation patterns to provide appropriate care and recognize deviations from normal.

Correct Answer: B

Rationale: In the context of pharmacology and nursing care of the newborn, understanding heat loss mechanisms is crucial for providing optimal care. The correct answer, option B - convection, is the type of heat loss reduced by skin-to-skin contact immediately following birth. This is because convection refers to heat loss through air currents passing over the baby's skin, and skin-to-skin contact helps to minimize this type of heat loss by providing a warm environment. Option A - radiation, involves heat loss through electromagnetic waves moving away from the baby's body. While important to consider, skin-to-skin contact primarily addresses convection heat loss. Option C - conduction, pertains to heat loss through direct contact with a cooler surface. While it is a factor in heat loss, skin-to-skin contact actually helps to reduce conduction heat loss by providing a warm surface for the baby. Option D - evaporation, refers to heat loss through moisture on the baby's skin evaporating into the air. While this is also a consideration in newborn care, skin-to-skin contact primarily targets convection heat loss. Educationally, this question highlights the practical application of thermoregulation principles in newborn care. It underscores the importance of immediate skin-to-skin contact as a simple yet effective intervention to promote thermal stability in newborns, a critical aspect of their well-being in the early postnatal period. Understanding and applying this knowledge equips nursing students with evidence-based practices to enhance the care and outcomes of neonates.