The nurse is working with a mother who has just delivered her third child, at 33 weeks' gestation. The mother says to the nurse, "This baby doesn't turn his head and suck like the older two children did. Why?" The best response by the nurse is:
1. "Every baby is different. This is just one variation of normal that we see on a regular basis."
2. "This baby might not have a rooting or sucking reflex, because she is premature."
3. "When she is wide awake and alert, she will probably root and suck even if she is early."
4. "She might be too tired from the birthing process and need a couple days to recover."
2
Rationale 1: Although each baby is unique and different from siblings, this response is not accurate.
Rationale 2: Preterm babies often have poor or absent root and suck reflexes. They also might not have a swallow reflex, and might require tube feedings temporarily.
Rationale 3: This statement is true of term infants, but this infant is preterm.
Rationale 4: Although birth is stressful to newborns, and some require a day or two of recovery to become fully alert, this infant is preterm.
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