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 D

Explanation

Choice A rationale:
Going to the emergency room for black stools without abdominal pain or cramping is not warranted in this situation.
Choice B rationale:
Having the client come to the office to check things out may not be necessary since black stools can be an expected side effect of iron supplements and do not necessarily indicate a problem.
Choice C rationale:
Asking about the client's diet is a valid question, but the black stools are likely due to iron supplements' effects and not related to dietary choices.
Choice D rationale:
Black stools are a known side effect of iron supplements. When iron is broken down during digestion, it can cause the stools to appear black or dark. As the client has no other concerning symptoms like abdominal pain or cramping, this response by the nurse reassures the client that the finding is expected and not a cause for alarm.

A. Repeat the contraction stress test in 24 hr. B. Prepare the client for admission to the hospital. C. Check the client's cervix for dilation. D. Document the findings as expected in the client records.

Correct Answer is B

Explanation

Choice A rationale: A positive contraction stress test warrants immediate attention and evaluation. Waiting for 24 hours to repeat the test could delay necessary interventions in case of fetal distress.
Choice B rationale: A positive contraction stress test indicates that there are late decelerations in the baby's heart rate during contractions, which may suggest fetal distress. In such cases, it is essential to admit the client to the hospital for further evaluation, monitoring, and appropriate management.
Choice C rationale: Checking the client's cervix for dilation is not the most appropriate action in response to a positive contraction stress test. Fetal well-being and assessment take priority in this situation.
Choice D rationale: A positive contraction stress test requires further action and should not be considered a routine finding. Proper management and evaluation are necessary when the test results are positive.

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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 speaking on the phone to a client on the phone who is pregnant and taking iron supplements for iron-deficiency anemia. The client reports that her stools are black but she has no abdominal pain or cramping. Which of the following responses by the nurse is appropriate?

Correct Answer is D

Explanation

A nurse is caring for a client who is at 38 weeks of gestation and has a positive contraction stress test. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who is at 34 weeks of gestation and has a suspected placenta previa. Which of the following actions should the nurse take?

A nurse is reinforcing teaching about common discomforts of pregnancy during the first trimester with a client who is pregnant. Which of the following manifestations should the nurse include in the teaching?

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A nurse is caring for a newborn who is small for gestational age (SGA). Which of the following findings should the nurse expect?

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 about strategies to calm a newborn with a client who is postpartum. Which of the following suggestions should the nurse make? (Select all that apply.)

A nurse is caring for a client who is at 32 weeks of gestation and is in labor. Which of the following medications is contraindicated for this client?

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