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With sudden extension of the head the arms abduct and

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with sudden extension of the head, the arms abduct and move upward and the handsform a “C.”abirb.com/test
Page 5Format:Multiple ChoiceClient Needs:Health Promotion and MaintenanceCognitive Level:AnalyzeIntegrated Process:Nursing ProcessPage and Header: 927, Table 25.15.Which reflex, if found in a 4-month-old infant, would cause the nurse to beconcerned?A) Plantar graspB) StepC) BabinskiD) Neck rightingAns: BFeedback:Appropriate appearance and disappearance of primitive reflexes, along with thedevelopment of protective reflexes, indicates a healthy neurologic system. The stepreflex is a primitive reflex that appears at birth and disappears at 4 to 8 weeks of age.The plantar grasp reflex is a primitive reflex that appears at birth and disappears atabout the age of 9 months. The Babinski reflex is a primitive reflex that appears atbirth and disappears around the age of 12 months. The neck righting reflex is aprotective reflex that appears around the age of 4 to 6 months and persists.abirb.com/test
Page 6Format:Multiple ChoiceClient Needs:Physiological Integrity: Basic Care and ComfortCognitive Level:ApplyIntegrated Process:Communication and DocumentationPage and Header: 929, Stools6.A new mother expresses concern to the nurse that her baby is crying and gruntingwhen passing stool. What is the nurse’sbestresponse to this observation?A) “This is normal behavior for infants unless the stool passed is hard and dry.”B) “This is normal behavior for infants due to the immaturity of thegastrointestinal system.”C) “This indicates a blockage in the intestine and must be reported to thehealth care provider.”D) “This is normal behavior for infants unless the stool passed is black orgreen.”Ans: AFeedback:Due to the immaturity of the gastrointestinal system, newborns and young infantsoften grunt, strain, or cry while attempting to have a bowel movement. This is not ofconcern unless the stool is hard and dry. Stool color and texture may changedepending on the foods that the infant is ingesting. Iron supplements may cause thestool to appear black or very dark green.abirb.com/test
Page 7Format:Multiple ChoiceClient Needs:Health Promotion and MaintenanceCognitive Level:ApplyIntegrated Process:Nursing ProcessPage and Header: 931, Take Note!7.The neonatal nurse assesses newborns for iron deficiency anemia. Which newbornis athighestrisk for this disorder?A) A postterm newbornB) A term newborn with jaundiceC) A newborn born to a diabetic motherD) A premature newbornAns: DFeedback:Maternal iron stores are transferred to the fetus throughout the last trimester ofpregnancy. Infants born prematurely miss all or at least a portion of this iron storetransfer, placing them at increased risk for iron deficiency anemia compared withterm infants. An infant having jaundice, having been born to a mother with diabetes,or having been born postterm does not significantly place the infant at risk for irondeficiency anemia.

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