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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A rationale:
Placing the client in a Trendelenburg position (head down and feet up) is not recommended after a convulsion in a pregnant client. It could potentially compromise blood flow to the brain and fetus. The priority after a convulsion is to ensure the client's airway and oxygenation.

Choice B rationale:
Assisting the client to void might be necessary during the course of care but is not the immediate action needed after a convulsion. The priority is to address airway and oxygenation needs.

Choice C rationale:
Administering oxygen to the client via face mask at 10 L/min is the correct action after the client experiences a convulsion. Eclampsia is a severe complication of preeclampsia, characterized by seizures. Providing oxygen ensures adequate oxygenation to the brain and vital organs during and after the convulsion.

Choice D rationale:
Giving calcium gluconate is not the appropriate action for eclampsia. Calcium gluconate is used to treat hyperkalemia and calcium channel blocker overdose. It does not address the underlying issue of eclampsia or prevent further convulsions. The immediate focus should be on managing the convulsions and ensuring the client's safety and well-being.

A. The mother and the father are both Rh positive. B. The mother is Rh positive and the father is Rh negative. C. The mother is Rh negative and the father is Rh positive. D. The mother and the father are both Rh negative.

Correct Answer is C

Explanation

Choice A rationale:

If both the mother and the father are Rh positive, there is no risk of hemolytic disease in the newborn due to Rh incompatibility. Hemolytic disease of the newborn occurs when the mother is Rh negative and the father is Rh positive.

Choice B rationale:

When the mother is Rh positive and the father is Rh negative, there is no risk of hemolytic disease in the newborn. Hemolytic disease results from Rh incompatibility, which occurs when the mother is Rh negative, and the father is Rh positive.

Choice C rationale:

This is the correct answer. Hemolytic disease of the newborn occurs when the mother is Rh negative, and the father is Rh positive. In such cases, the baby may inherit the Rh factor from the father, leading to Rh incompatibility between the mother and the baby's blood, potentially causing hemolytic disease.

Choice D rationale:

If both the mother and the father are Rh negative, there is no risk of hemolytic disease in the newborn due to Rh incompatibility. Hemolytic disease of the newborn occurs when the mother is Rh negative and the father is Rh positive.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has developed eclampsia. Which of the following actions should the nurse implement after the client experiences a convulsion?

Correct Answer is C

Explanation

A nurse is developing an educational program about hemolytic disease in newborns for a group of newly licensed nurses. Which of the following genetic information should the nurse include in the program as a cause of hemolytic disease?

Correct Answer is C

Explanation

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