A nurse is caring for a newborn and assessing newborn reflexes.

To elicit the Moro reflex, what action should the nurse take?

Turn the newborn’s head quickly to one side.

Perform a sharp hand clap near the infant.

Place a finger at the base of the newborn’s toes.

Hold the newborn vertically allowing one foot to touch the table surface.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Turning the newborn’s head quickly to one side does not elicit the Moro reflex. This action can elicit the tonic neck reflex, also known as the “fencing” reflex.
Choice B rationale
Performing a sharp hand clap near the infant can elicit the Moro reflex. This reflex is a response to a sudden loss of support and involves three distinct components: spreading out the arms (abduction), unspreading the arms (adduction), and usually crying.
Choice C rationale
Placing a finger at the base of the newborn’s toes elicits the Babinski reflex, not the Moro reflex.
Choice D rationale
Holding the newborn vertically allowing one foot to touch the table surface does not elicit the Moro reflex. This action can elicit the stepping or walking reflex.

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Correct Answer is C

Explanation

Choice A rationale
The Babinski reflex is a normal reflex in infants that disappears by 12 months of age. It involves fanning out of the toes when the sole of the foot is stroked, and it doesn’t promote latching during breastfeeding.
Choice B rationale
The stepping reflex is a primitive reflex that makes newborns appear to take steps or dance when held upright with their feet touching a solid surface. It doesn’t promote latching during breastfeeding.
Choice C rationale
The rooting reflex helps promote latching during breastfeeding. When the corner of the baby’s mouth is touched, the baby will turn his or her head and open his or her mouth to follow and “root” in the direction of the stroking. This helps the baby find the breast or bottle to start feeding.
Choice D rationale
The Moro reflex, also known as the startle reflex, involves the baby throwing back his or her head, extending out the arms and legs, crying, then pulling the arms and legs back in. It doesn’t promote latching during breastfeeding.

A. Drink 48 to 64 ounces of water daily. B. Consume 40 to 90 g of protein daily. C. Limit intake of whole grains, raw fruits, and vegetables. D. Avoid salting of foods during cooking

Correct Answer is A

Explanation

The correct answer is choice A. Drink 48 to 64 ounces of water daily.

Choice A rationale:

Drinking 48 to 64 ounces of water daily is recommended to help maintain hydration and support overall health during pregnancy, especially for those with mild preeclampsia.

Choice B rationale:

While protein intake is important, the recommended amount for pregnant women is generally higher than 40 to 90 grams per day. The exact amount can vary based on individual needs, but typically, pregnant women are advised to consume around 71 grams of protein daily.

Choice C rationale:

Limiting intake of whole grains, raw fruits, and vegetables is not recommended. These foods are rich in essential nutrients and fiber, which are beneficial for both the mother and the baby.

Choice D rationale:

Avoiding salting of foods during cooking can help manage blood pressure, but it is not the primary focus of dietary recommendations for preeclampsia. Reducing overall sodium intake is more important.

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A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, what action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting a client with breastfeeding. The nurse explains that which of the following reflexes will promote the newborn to latch?

Correct Answer is C

Explanation

A nurse is completing discharge teaching to a client in her 35th week of pregnancy who has mild preeclampsia. Which of the following information about nutrition should be included in the teaching?

Correct Answer is A

Explanation

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A nurse is caring for a newborn and assessing newborn reflexes.

To elicit the Moro reflex, what action should the nurse take?