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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? 

A.

Turn the newborn’s head quickly to one side.

B.

Perform a sharp hand clap near the infant.

C.

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

D.

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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Related Questions

Correct Answer is B

Explanation

The correct answer is choiceB. Expressions of excitement.

Choice A rationale:

Eagerness to learn newborn care skills is more characteristic of the “taking-hold” phase, which follows the “taking-in” phase.During the taking-hold phase, the mother becomes more independent and starts to take an active role in caring for her newborn.

Choice B rationale:

Expressions of excitement are typical during the “taking-in” phase. This phase occurs in the first 1-2 days postpartum, where the mother is primarily focused on herself and her birth experience.She may be excited and talkative about the birth process.

Choice C rationale:

Focus on the family unit and its members is more aligned with the “letting-go” phase, which is the final phase of maternal postpartum adjustment.In this phase, the mother starts to integrate the newborn into the family and adjusts to her new role.

Choice D rationale:

Lack of appetite can occur during the “taking-in” phase due to exhaustion and the physical demands of labor, but it is not a defining characteristic of this phase.

Correct Answer is A

Explanation

Choice A rationale
The client’s symptoms and lab results are consistent with HELLP Syndrome, a severe form of preeclampsia. HELLP stands for Hemolysis, Elevated Liver enzymes, and Low Platelet count. The client’s elevated liver enzymes and low platelets, along with the reported symptoms, are indicative of this condition.
Choice B rationale
While the client’s high blood pressure could suggest Postpartum hypertension, the presence of severe headaches, visual disturbances, right upper quadrant pain, and abnormal lab results point more towards HELLP Syndrome.
Choice C rationale
Hypertension in pregnancy could be a possibility, but it does not explain all of the client’s symptoms and lab results, particularly the elevated liver enzymes and low platelets.
Choice D rationale

Superimposed preeclampsia is a condition where a pregnant woman with chronic hypertension develops preeclampsia. However, the client’s severe symptoms and lab results are more indicative of HELLP Syndrome.

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