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
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale: Around 10 to 12 months of age, babies develop more advanced oral motor skills and can start to use their tongue to push solid objects out of their mouth. This is a natural reflex that helps prevent choking as they continue to learn how to eat solid foods.
Choice B rationale: Between 8 to 10 months of age, babies start to develop the ability to chew and swallow soft, cooked food. At this stage, they are typically introduced to mashed or finely chopped solid foods to complement their breast milk or formula diet.
Choice C rationale: Newborns typically start with bottle-feeding or breastfeeding. As they grow and develop, they eventually transition to drinking from a cup, which is usually introduced around 6 to 9 months of age. At this stage, the baby is held by another person while they drink from a cup with assistance.
Choice D rationale: Around 6 to 8 months of age, infants start showing an interest in self-feeding and may begin experimenting with a spoon. They may try to scoop food with a spoon but often need assistance and are still primarily dependent on being fed by a caregiver.
Correct Answer is C
Explanation
Choice A rationale: A breech presentation means that the baby's buttocks or feet are the presenting part, not the shoulder.
Choice B rationale: Vertex presentation refers to a head-down position of the baby with the occiput (back of the head) as the presenting part. In the RSA position, the baby is in vertex presentation, but the specific part facing the mother's right side is the shoulder.
Choice C rationale: RSA (Right Sacrum Anterior) indicates that the fetus is in a vertex presentation with the head pointing down and the back of the baby's head (occiput) facing the mother's right side. The shoulder is the presenting part of this position.
Choice D rationale; Mentum refers to the chin of the baby. A mentum presentation (also called face presentation) means that the baby's face is the presenting part, not the shoulder.
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