A nurse is assisting in the care of a client on the medical-surgical unit.

Exhibits

Which of the following client findings suggest that the nurse should hold the tube feeding and notify the provider? Select all that apply.

A. Turn the newborn's head quickly to one side while they are sleeping: Turning the head quickly elicits the tonic neck reflex (also called the “fencing reflex”), not the Moro reflex. This reflex causes the newborn to extend the arm and leg on the side the head is turned while flexing the opposite limbs.

B. Place a finger in the newborn's palm: Placing a finger in the newborn’s palm elicits the palmar grasp reflex, causing the infant to curl their fingers around the object. It does not trigger the Moro reflex, which involves a startle response of the whole body.

C. Clap hands after laying the newborn on a flat surface: The Moro reflex is elicited by a sudden loss of support or a startle stimulus, such as a loud clap or gentle dropping of the infant’s head slightly backward while lying on a flat surface. The newborn responds with abduction and extension of the arms, followed by adduction and often crying.

D. Hold the newborn upright with one foot touching the crib surface: This action is used to elicit the stepping or walking reflex, in which the newborn makes stepping movements. It does not elicit the Moro reflex, which is a response to sudden displacement or loud stimuli.

A. Amniotic fluid color: Assessing amniotic fluid color is important to identify meconium-stained or bloody fluid, which can indicate fetal compromise or infection. While this provides valuable information, it does not provide immediate data about fetal well-being, making it secondary to continuous fetal monitoring.

B. The client's temperature: Maternal temperature is monitored to detect infection, especially after rupture of membranes. However, fever develops over time, so it is not the most immediate priority immediately following amniotomy. Early assessment focuses on detecting acute fetal compromise.

C. Frequency of contractions: Monitoring contraction frequency, duration, and intensity is essential for assessing labor progress. While contraction patterns guide labor management, fetal response to contractions is a higher priority after membrane rupture, as sudden changes can affect fetal oxygenation.

D. Fetal heart rate: Fetal heart rate assessment is the priority immediately after an amniotomy because sudden changes in amniotic fluid volume, umbilical cord prolapse, or cord compression can compromise fetal oxygenation. Early identification of decelerations or abnormal patterns allows rapid intervention to prevent fetal injury.