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:
Placing only part of the nipple in the baby's mouth may result in an ineffective latch, leading to breastfeeding difficulties.
Choice B rationale:
Placing the nipple and 2 to 3 cm of areolar tissue around the nipple into the baby’s mouth aids in adequately compressing the milk ducts. This placement decreases stress on the nipple and prevents cracking and soreness.
Choice C rationale:
Placing the entire areolar is not appropriate.
Choice D rationale:
While babies do have natural instincts to breastfeed, it is essential to provide the mother with specific guidance on achieving a proper latch to ensure successful breastfeeding.

A. "I will stop breastfeeding until I am done with the antibiotics." B. "I'll feed my baby every 2 hours." C. "I won't wear a bra during the daytime." D. “I’ll apply cold compresses 20 min before each feeding."

Correct Answer is D

Explanation

Choice A rationale: Stopping breastfeeding is not an appropriate response to breast engorgement. Continuing to breastfeed frequently and effectively can help relieve the engorgement and ensure adequate milk supply.
Choice B rationale: While frequent breastfeeding is beneficial for both the baby and mother, this statement does not directly address breast engorgement.
Choice C rationale: Wearing a supportive bra during the daytime can actually help reduce breast engorgement and discomfort by providing gentle pressure and support to the breasts.
Choice D rationale: Breast engorgement is a common issue for breastfeeding mothers, especially during the early days after delivery. Applying cold compresses to the breasts before each feeding can help reduce swelling and discomfort associated with engorgement, making it easier for the baby to latch onto the breast.

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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 assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the baby's mouth, which of the following responses by the nurse is appropriate?

Correct Answer is B

Explanation

A home health care nurse is reinforcing teaching about breast engorgement with a client who is postpartum and is breastfeeding her newborn. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is D

Explanation

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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.)