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:
A newborn can lose up to 10% of their birth weight in the first few days after birth, which is considered normal. By 7-14 days of age, the baby should have regained their birth weight if breastfeeding effectively.
Choice B rationale:
Gaining 0.25 oz (7 grams) per day after the fourth day of life is not a standard guideline for assessing effective breastfeeding.
Choice C rationale:
Expecting the baby to have less than 5 wet diapers per day after the fourth day of life may indicate dehydration or inadequate breastfeeding, which is not a sign of effective breastfeeding.
Choice D rationale:
Expecting the baby to feed constantly during the first week of life is not necessarily an indicator of effective breastfeeding. While frequent feeding is normal in the early days, the baby should be able to effectively feed and show signs of satiety after nursing.
Correct Answer is C
Explanation
Choice A rationale: While colostrum is present in the first few days after delivery, it takes a few more days for breast milk to "come in" and increase in volume.
Choice B rationale: Waiting for 6 to 8 days for breast milk to come in would be too long after childbirth. Breast milk typically "comes in" sooner, around 3 to 5 days after delivery.
Choice C rationale: Colostrum, the first milk, is typically produced in small amounts during the first few days after delivery. Breast milk usually "comes in" or increases in volume around 3 to 5 days after childbirth. This transition from colostrum to mature milk is normal and expected.
Choice D rationale: Waiting for 10 days for breast milk to come in would be too long after childbirth. Breast milk typically "comes in" sooner, around 3 to 5 days after delivery.
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