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.
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Related Questions
Correct Answer is D
Explanation
A. Changing the dressing on a client's IV site: This is a sterile procedure and requires the nurse’s clinical expertise. It cannot be delegated to assistive personnel (AP).
B. Suctioning a client's new tracheostomy: Suctioning a tracheostomy, especially a new one, is a sterile procedure requiring clinical judgment and skill, which is beyond the scope of assistive personnel.
C. Evaluating a client's risk for developing pressure injuries: This is an assessment task that requires clinical judgment and critical thinking. It falls under the nurse’s scope of practice and should not be delegated to AP.
D. Administering a large-volume enema to a client: Assisting with or administering an enema is a task that can be delegated to assistive personnel, as it is within their scope of practice, provided the client is stable and the procedure does not require complex judgment.
Correct Answer is D
Explanation
A. Incorrect. Upper gastrointestinal series typically involve oral ingestion of a contrast medium, not an injection.
B. Incorrect. Clients are usually instructed to fast before an upper gastrointestinal series, not consume breakfast.
C. Incorrect. While it's generally advisable to have someone accompany the client for procedures involving sedation or anesthesia, fluoroscopy itself does not usually require sedation, and the client can typically drive home afterward.
D. Correct. Prior to an upper gastrointestinal series, clients are usually required to drink a contrast medium to outline the digestive tract for fluoroscopy imaging.
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