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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The nurse should not tell the client that she cannot have an amniocentesis until she is at least 35 years of age. Age is not the primary factor for determining the eligibility for an amniocentesis. Amniocentesis is typically performed when there is a medical indication, such as advanced maternal age, abnormal prenatal screening, or a family history of genetic disorders.
Choice B rationale:
The nurse should not schedule the amniocentesis for later today without further clarification from the provider. Scheduling medical procedures without the provider's approval is not within the nurse's scope of practice and could lead to potential risks.
Choice C rationale:
This is the correct answer. The nurse should explain to the client that amniocentesis is a procedure used to determine if the baby has genetic or congenital disorders. It involves the extraction of a small amount of amniotic fluid to analyze the fetal cells for genetic abnormalities.
Choice D rationale:
The nurse should not tell the client that her provider will schedule a chorionic villus sampling (CVS) to determine the sex of the baby. CVS is another prenatal diagnostic test, but its primary purpose is to detect genetic disorders early in pregnancy, not to determine the baby's sex.
Correct Answer is B
Explanation
Choice A rationale:
Swaddling the baby tightly with his legs extended before laying him down to sleep is not a recommended practice, as it can increase the risk of hip dysplasia. Instead, the baby should be placed on their back in a safe sleep environment.
Choice B rationale:
This statement is correct because monitoring the baby's urinary output is essential in ensuring adequate hydration and proper kidney function. Less than six wet diapers a day could be a sign of dehydration and should be promptly reported to the pediatrician.
Choice C rationale:
It is not necessary to retract the foreskin to clean the baby's penis during each bath. The foreskin should be left alone and not forcibly retracted until it naturally loosens, usually around the age of 3 to 5 years.
Choice D rationale:
Applying triple antibiotic ointment on the baby's umbilical cord is not recommended, as the standard practice is to keep the umbilical cord clean and dry. This helps it to fall off naturally within a week or two after birth, reducing the risk of infection.
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