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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Regular physical activity is an important part of managing gestational diabetes. Most guidelines recommend at least 30 minutes of moderate-intensity exercise on most days of the week. Reducing the exercise schedule to only 3 days a week may not provide enough activity to help regulate blood glucose levels.
Choice B rationale
Limiting carbohydrates to 50% of caloric intake can be a part of a balanced diet for managing gestational diabetes. Carbohydrates have the biggest effect on blood sugar levels, so monitoring and regulating carbohydrate intake is key.
Choice C rationale
Glyburide is an oral medication that can be used to manage gestational diabetes when diet and exercise are not enough. It helps to lower blood glucose levels by stimulating the pancreas to release more insulin.
Choice D rationale
It is true that women who have had gestational diabetes are at an increased risk of developing type 2 diabetes later in life. Therefore, this statement does not indicate a need for further teaching.
Correct Answer is B
Explanation
Choice A rationale
Inserting an indwelling urinary catheter is not the priority nursing action. While it may be necessary later, especially if the client goes to surgery, it is not the immediate concern.
Choice B rationale
Initiating IV access is the correct action. The client is losing blood rapidly, has hypotension, and tachycardia. IV access will allow IV fluids and blood to be administered quickly if hypovolemia develops.
Choice C rationale
Witnessing the signature for informed consent for surgery is not the priority nursing action. While consent will be necessary if the client needs a cesarean section, the immediate concern is stabilizing the client.
Choice D rationale
Preparing the abdominal and perineal areas is not the priority nursing action. This would be done as part of surgical preparation if a cesarean section is needed, but it is not the immediate concern.
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