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
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Related Questions
Correct Answer is A
Explanation
Choice A rationale: The correct term to document this finding is "Quickening." Quickening refers to the first perception of fetal movement by the pregnant woman, usually described as light fluttering or sensation of movement in the abdomen. It is an exciting milestone for pregnant women and often occurs around 18 to 20 weeks of gestation. It is a significant moment as it indicates the woman can feel the baby's movements, signifying the fetus's increasing activity and growth.
Choice B rationale: Ballottement is a physical examination technique used to assess the fetus's position and movement within the amniotic fluid during pregnancy. It involves a gentle tap on the mother's abdomen to feel the fetus bounce or float in the amniotic fluid.
Choice C rationale: Chloasma, also known as the "mask of pregnancy," refers to dark patches of skin that may appear on the face during pregnancy due to hormonal changes. It is not related to the sensation of fetal movement.
Choice D rationale: Lightening, also known as "engagement," is the process in late pregnancy when the baby's head descends into the pelvis, preparing for childbirth. It often occurs a few weeks before labor begins and can result in the mother feeling less pressure on her diaphragm, which may make breathing easier. It is not related to the perception of fetal movement described by the client.
Correct Answer is A
Explanation
Choice A rationale: Misoprostol is a prostaglandin analog and is contraindicated for use during labor at 32 weeks of gestation as it can lead to uterine hyperstimulation, which may pose a risk to the preterm fetus.
Choice B rationale: Folic acid is a vitamin supplement and is not contraindicated during labor. However, it is typically taken earlier in pregnancy to prevent neural tube defects.
Choice C rationale: Nifedipine is a calcium channel blocker that may be used to suppress preterm labor, and it is not contraindicated at 32 weeks of gestation.
Choice D rationale: Terbutaline is a beta-adrenergic agonist that may be used to relax the uterine smooth muscles and inhibit preterm labor. It is not contraindicated at 32 weeks of gestation.
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