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

Answer and Explanation

The Correct Answer is A

A. Turning the newborn's head quickly to one side does not elicit the Moro reflex. This action may test the tonic neck reflex instead, which is different from the Moro reflex.
B. Placing a finger in the newborn's palm will elicit the grasp reflex, not the Moro reflex. The grasp reflex involves the newborn closing their hand around the finger.
C. Clapping hands or creating a sudden loud noise after laying the newborn on a flat surface will startle the newborn, causing the Moro reflex. This reflex involves the baby extending their arms, legs, and fingers, followed by bringing them together as if in a protective gesture.
D. Holding the newborn upright with one foot touching the crib surface tests the stepping reflex, not the Moro reflex. The stepping reflex involves the baby making walking-like movements.

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Correct Answer is A

Explanation

- Rationale for A: Serving meals with plastic utensils is a safety measure to prevent self-harm. Metal utensils can be used as weapons, so plastic is a safer alternative. This action reflects the priority of maintaining a safe environment for the client.
- Rationale for B: Assigning another client to accompany the client to therapy sessions is not advisable. It may violate privacy and confidentiality, and it is not the responsibility of other clients to monitor safety.
- Rationale for C: Assigning the client to a private room could be beneficial for monitoring purposes, but it does not directly prevent self-harm. It is also important to consider that constant observation is necessary regardless of room assignment.
- Rationale for D: Checking on the client every 4 hours is not sufficient for a client who is at high risk for suicide. More frequent monitoring is needed to ensure the client's safety and to intervene promptly if necessary.

A. Vomiting B. Confusion C. Incontinence D. Tinnitus

Correct Answer is B

Explanation

A. Vomiting is not a common adverse effect of electroconvulsive therapy (ECT). Nausea may occur, but vomiting is less common.
B. Confusion is a common adverse effect of ECT, especially immediately following the procedure. It typically resolves within a short time after the treatment.
C. Incontinence is not typically associated with ECT. However, urinary retention may occur in some cases.
D. Tinnitus (ringing in the ears) is not a common adverse effect of ECT. However, some clients may experience temporary hearing disturbances immediately following the procedure.

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