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 D

Explanation

The first action the nurse should take is to reevaluate the client's response to the medication in 30 min. Hydromorphone has an onset of action of 15 to 30 minutes when taken orally ¹. Therefore, it may take some time for the medication to reach its full eﬀect.

Option a is incorrect because it may not be necessary to contact the provider for more pain medication until after reevaluating the client's response to the medication.

Option b is incorrect because teaching relaxation techniques may not provide immediate relief for acute pain.

Option c is incorrect because documenting the client's reaction to the administration of medication should be done after reevaluating their response to the medication.

A. Increased heart rate. B. Increased cardiac output. C. Decreased urinary output. D. Decreased potassium level.

Correct Answer is B

Explanation

The nurse should include increased cardiac output as an expected eﬀect of digoxin when reinforcing teaching with the client. Digoxin is a positive inotropic medication that strengthens the force of contraction of the heart, resulting in increased cardiac output.

Option a, increased heart rate, is not an expected eﬀect of digoxin. Digoxin may actually decrease heart rate by exerting a negative chronotropic eﬀect.

Option c, decreased urinary output, is not an expected eﬀect of digoxin. In fact, digoxin does not directly aﬀect urinary output.

Option d, decreased potassium level, is not an expected eﬀect of digoxin. However, digoxin can increase the risk of hypokalemia, so it is important to monitor the client's potassium levels while on the medication.

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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 collecting data from a client who is postoperative and received hydromorphone 4 mg PO 15 min ago. The client tells the nurse, "My pain level is still 8 on a 0 to 10 scale." Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client who has a new prescription for digoxin to treat heart failure. Which of the following should the nurse include as an expected eﬀect of this medication?

Correct Answer is B

Explanation

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