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 C
Explanation
Choice A rationale
The fundus should not be soft or to the right of the umbilicus 12 hours postpartum. A soft or displaced fundus could indicate uterine atony or a full bladder, both of which require intervention.
Choice B rationale
The fundus should not be soft or above the umbilicus 12 hours postpartum. This could indicate uterine atony, which could lead to postpartum hemorrhage.
Choice C rationale
The fundus should be firm and at the level of the umbilicus 12 hours postpartum. This indicates that the uterus is contracting properly to prevent excessive bleeding.
Choice D rationale
The fundus should not be to the left of the umbilicus 12 hours postpartum. This could indicate a full bladder, which can displace the uterus and interfere with uterine contractions
Correct Answer is D
Explanation
Choice A rationale
Vaginal discharge, or leukorrhea, often increases during pregnancy due to higher levels of estrogen and greater blood flow to the vaginal area. It does not typically decrease before labor.
Choice B rationale
Weight gain is expected during pregnancy, but a sudden gain of 0.5 to 1.3 kg is not a typical sign that labor is about to start.
Choice C rationale
Urinary retention is not a typical sign that labor is about to start. In fact, many women find that they need to urinate more frequently as labor approaches, due to increased pressure on the bladder.
Choice D rationale
A surge of energy, often called “nesting,” can be a sign that labor is about to start. Some women experience a burst of energy and the desire to prepare their home for the baby in the days or hours before labor begins.
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