A nurse is assessing the reflexes of a term newborn. After placing the newborn in the supine position, which of the following methods should the nurse use to elicit the Moro reflex?
Make a loud noise above the newborn.
Touch the newborn's cheek with a finger.
Tap the newborn's forehead with a finger.
Turn the newborn's head to one side.
The Correct Answer is A
Choice A rationale:
The Moro reflex, also known as the startle reflex, is elicited by making a loud noise above the newborn, causing them to extend their arms and legs and then bringing them back to the body in a hugging motion. This reflex is a normal developmental response in term newborns.
Choice B rationale:
Touching the newborn's cheek with a finger elicits the rooting reflex, where the newborn turns their head toward the stimulus, searching for a nipple or object to suck. It is a different reflex and not the Moro reflex.
Choice C rationale:
Tapping the newborn's forehead with a finger does not elicit any specific reflex. This action is not related to the Moro reflex.
Choice D rationale:
Turning the newborn's head to one side elicits the asymmetric tonic neck reflex (ATNR), not the Moro reflex. In ATNR, when the head is turned to one side, the arm on that side extends while the opposite arm flexes.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D,C,B,A
Explanation
Correct Answer is C
Explanation
Choice A rationale:
The nurse should not include the information about beginning Kegel exercises 6 to 7 weeks after delivery because Kegel exercises are pelvic floor exercises that help improve bladder control and should be started earlier, immediately after childbirth. Delaying the exercises for 6 to 7 weeks could result in weaker pelvic floor muscles and potentially exacerbate postpartum urinary issues.
Choice B rationale:
The nurse should not include the information that the client doesn't need to use birth control if exclusively breastfeeding. While exclusive breastfeeding can provide some natural contraceptive effect, it is not a reliable method, and there is still a risk of pregnancy during the postpartum period. The nurse should advise the client to use appropriate birth control methods to prevent unintended pregnancies.
Choice C rationale:
This is the correct answer. The nurse should include information about the client's breasts becoming firm and tender 3 to 5 days after delivery. This is a normal physiological response known as engorgement, which occurs as the breasts prepare for breastfeeding.
Choice D rationale:
The nurse should not inform the client that her bleeding will remain bright red for the next 6 to 8 weeks. While some postpartum bleeding is normal (known as lochia), the color and amount of bleeding change over time. Initially, it is bright red and gradually transitions to a lighter color over the following weeks.
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