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 C

To elicit the Moro reﬂex, the nurse should clap hands after laying the newborn on a ﬂat surface. The Moro reﬂex, also known as the startle reﬂex, is an involuntary motor response that infants develop shortly after birth. Loud noises and sudden movements can trigger a baby’s Moro reﬂex.

Option a is incorrect because turning the newborn's head quickly to one side while they are sleeping may not elicit the Moro reﬂex.

Option b is incorrect because placing a finger in the newborn's palm may elicit the grasp reﬂex, not the Moro reﬂex.

Option d is incorrect because holding the newborn upright with one foot touching the crib surface may not elicit the Moro reﬂex.

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Correct Answer is A

Explanation

After a patient dies, postmortem care includes preparing them for family viewing. The nurse should place the body in the supine position, with the arms at the sides and the head on a pillow. Then elevate the head of the bed 30 degrees to prevent discoloration from blood settling in the face .

The other options are not correct because:

b) The nurse should cleanse the client's body while wearing appropriate personal protective equipment (PPE) based on indications for isolation precautions, not necessarily sterile gloves.

c) If the patient wore dentures and your facility’s policy permits, gently insert them; then close the mouth

d) The nurse should close the eyes by gently pressing on the lids with their fingertips. If they don’t stay closed, place moist coton balls on the eyelids for a few minutes, and then try again to close them. Surgical tape is not mentioned as necessary .

A. Call EMS if a seizure lasts 5 min or more. B. Restrain the child at the onset of the seizure. C. Oﬀer the child a bubble bath every evening. D. Place the child in a prone position during the seizure.

Correct Answer is A

Explanation

The correct answer is a. Call EMS if a seizure lasts 5 minutes or more.

Explanation:

When providing home care instructions for a child with a seizure disorder, it is important to educate the parents about appropriate actions during a seizure. Calling emergency medical services (EMS) if a seizure lasts 5 minutes or more is crucial because it may indicate a condition called status epilepticus, which is a prolonged seizure or a series of seizures without full recovery of consciousness between them. Status epilepticus is a medical emergency that requires immediate medical intervention.

Option b, restraining the child at the onset of a seizure, is not recommended. Restraint can potentially cause harm to the child and increase the risk of injury. It is advised to create a safe environment by removing any nearby objects that could cause injury and placing a pillow or cushion under the child's head to prevent head injury.

Option c, oﬀering the child a bubble bath every evening, is not specifically related to seizure management. Bathing routines can be continued as long as they are safe and supervised. However, it is important to ensure the child's safety during bathing, such as providing adequate supervision to prevent drowning or injury.

Option d, placing the child in a prone position during a seizure, is not recommended. Placing the child in a prone position (face down) during a seizure can obstruct the airway and increase the risk of respiratory complications. The child should be placed on their side, in a recovery position, to facilitate drainage of saliva or other ﬂuids and prevent choking.

Overall, the most important instruction for the parents is to recognize the signs of prolonged seizure activity and to seek immediate medical assistance by calling EMS if a seizure lasts 5 minutes or more.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing postmortem care for a client prior to the family viewing the body. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is reinforcing teaching about home care with the parents of a child who has a seizure disorder. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

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