A nurse in the newborn nursery is collecting data about a newborn's Moro reflex. Which of the following actions should the nurse take to elicit this reflex?
Turn the newborn's head quickly to one side while they are sleeping.
Place a finger in the newborn's palm.
Clap hands after laying the newborn on a flat surface.
Hold the newborn upright with one foot touching the crib surface
None
None
The Correct Answer is C
A. Turn the newborn's head quickly to one side while they are sleeping: This action does not elicit the Moro reflex. The Moro reflex is a response to a sudden loss of support, not a head-turning motion.
B. Place a finger in the newborn's palm: This action would elicit the palmar grasp reflex, not the Moro reflex.
C. Clap hands after laying the newborn on a flat surface: The Moro reflex is triggered by a sudden, loud noise or movement, such as clapping hands. This response causes the newborn to extend and then quickly flex the arms, a characteristic sign of the reflex.
D. Hold the newborn upright with one foot touching the crib surface: This action is not related to the Moro reflex. The stepping reflex is elicited by holding the newborn upright with their feet touching a surface, not the Moro reflex.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Hemoglobin (Hgb) level of 20 g/dL is significantly elevated and could indicate polycythemia, which is a common complication of COPD. Polycythemia can lead to increased blood viscosity and thrombotic events, such as stroke or myocardial infarction. Therefore, this finding requires immediate attention and further evaluation.
B. Oxygen saturation of 925% is not physiologically possible and is likely an erroneous reading. However, this extreme value is unlikely to represent a clinically significant issue. It may be a result of equipment malfunction or improper calibration.
C. A productive cough with green sputum is a common symptom in patients with COPD, often indicative of a respiratory infection. While it warrants monitoring and may require treatment, it is not as immediately concerning as other findings.
D. Chest x-ray showing hyperinflation of the lungs is a characteristic finding in COPD and is expected in patients with this condition. While it confirms the diagnosis and may indicate disease severity, it does not represent an acute change that requires immediate intervention.
Correct Answer is B
Explanation
A. Resuming a regular diet 3 days after the procedure may not be appropriate, as dietary restrictions may be necessary depending on the procedure and the individual's condition.
B. Allowing the adolescent to take a shower 1 day after the procedure is appropriate, as it promotes cleanliness and comfort without interfering with the healing process.
C. Beginning exercise 2 days after the procedure may not be advisable, as the adolescent may need time for rest and recovery, depending on the extent of the procedure and any associated complications.
D. Returning to school 1 week after the procedure may vary depending on the individual's recovery and any restrictions recommended by the healthcare provider.
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