A nurse is assisting in collecting data for a gestational age assessment on a newborn. Which of the following should the nurse check during a neuromuscular assessment? (Select all that apply.)

Scarf sign

Arm recoil

Moro reflex

Heel to ear

Popliteal angle

Answer and Explanation

Correct Answer : A,B,C

Choice A rationale: The Scarf sign assesses the range of motion of the newborn's shoulder and elbow joint. It measures the ability of the newborn's arm to be brought across the chest.
Choice B rationale: Arm recoil measures the degree of resistance and recoil of the newborn's arm when it is extended and then flexed against the chest. This reflex provides information about the newborn's muscle tone and neuromuscular maturity.
Choice C rationale: The Moro reflex, also known as the startle reflex, is elicited by a sudden change in the newborn's position or by a loud noise. It involves an initial extension and abduction of the arms, followed by a flexion and adduction. This reflex helps assess the newborn's neurologic and neuromuscular maturity.
Choice D rationale: "Heel to ear" is not a standard neuromuscular assessment used in the gestational age assessment. It may be an incorrect or unclear term.
Choice E rationale: The popliteal angle is not a neuromuscular assessment used in the gestational age assessment. It measures the angle of flexion in the knee joint and is not directly related to neuromuscular maturity

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Correct Answer is B

Explanation

Choice A rationale: This response assumes that the couple's religious beliefs are relevant to them, which may not be the case. It is not appropriate for the nurse to suggest involving their minister without knowing their preferences or beliefs.
Choice B rationale: This response acknowledges the couple's emotional experience and shows empathy toward their grief. It offers support and reassurance that the nurse will be available to help them through this difficult time.
Choice C rationale: While this statement may be factually true, it is not empathetic or supportive of the couple's current emotional state. It may come across as dismissive of their feelings and minimize their grief.
Choice D rationale: While gathering information about the pregnancy is essential for the medical record, this question does not address the couple's emotional needs. It is more appropriate to focus on offering emotional support and assistance rather than immediately delving into clinical details.

A. Reinforce teaching about ways to increase rest and sleep. B. Arrange for counseling to help the client cope with the stress of being a parent. C. Request a prescription for antidepressant medication. D. Use a postpartum depression screening tool with the client.

Correct Answer is D

Explanation

Choice A rationale: While adequate rest and sleep are essential postpartum, the client's symptoms of feeling down and sad may be indicative of postpartum depression and should be further evaluated.
Choice B rationale: Counseling may be helpful, but the priority is to first assess and screen for postpartum depression before making additional recommendations.
Choice C rationale: While antidepressant medications might be necessary for postpartum depression, the initial step should be to assess and screen for depression using the appropriate tool.
Choice D rationale: The client's statement and symptoms raise concerns about possible postpartum depression. Using a postpartum depression screening tool will help the nurse assess the severity of the client's symptoms and determine the appropriate course of action.

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A nurse is assisting in collecting data for a gestational age assessment on a newborn. Which of the following should the nurse check during a neuromuscular assessment? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a couple who experienced a fetal death at 37 weeks of gestation. Which of the following responses by the nurse is therapeutic?

Correct Answer is B

Explanation

A nurse is caring for a client who is 2 weeks postpartum. The client tells the nurse, "I feel really down and sad lately. I have no energy and I feel like I'm going to cry." Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is caring for a client who is 1 day postpartum. The client tells the nurse, "The baby has been breathing funny, fast and slow, off and on." Which of the following responses should the nurse make?

A nurse is reinforcing teaching with a client who is at 6 weeks of gestation. The client tells the nurse that she smokes one pack of cigarettes per day. The nurse should instruct the client that her newborn is at increased risk for which of the following clinical manifestations?

A nurse is collecting data about reflexes from a newborn. Which of the following actions should the nurse take to elicit the newborn's Moro reflex?

A nurse is collecting data from a newborn. Which of the following anatomical landmarks should the nurse use to measure chest circumference?

A nurse is collecting data from a newborn who weighs 5,160 g (11 lb, 6 oz) and whose mother has diabetes mellitus. For which of the following data should the nurse monitor?

A nurse is reinforcing teaching with a newly licensed nurse about the complications associated with maternal gestational diabetes. Which of the following complications should the nurse include?

A nurse is performing Leopold maneuvers on a client who is in labor and determines the fetus is in an RSA position. Which of the following fetal presentations should the nurse document in the client's medical record?

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