A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse should take which of the following actions?

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

Perform a sharp hand clap near the infant.

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

Turn the newborn's head quickly to one side.

Answer and Explanation

The Correct Answer is B

A) Hold the newborn vertically allowing one foot to touch the table surface:

This action describes eliciting the Babinski reflex, not the Moro reflex. The Babinski reflex is elicited by stroking the sole of the foot, causing the toes to fan out and the big toe to dorsiflex while the other toes fan out.

B) Perform a sharp hand clap near the infant:

This action correctly describes eliciting the Moro reflex. The Moro reflex, also known as the startle reflex, is elicited by a sudden movement or loud noise near the infant. The infant responds by extending the arms outward, then bringing them together as if embracing.

C) Place a finger at the base of the newborn's toes:

This action describes eliciting the plantar grasp reflex, not the Moro reflex. The plantar grasp reflex is elicited by stimulating the sole of the foot, causing the toes to curl downward in a grasping motion.

D) Turn the newborn's head quickly to one side:

This action describes eliciting the tonic neck reflex, also known as the fencing reflex, not the Moro reflex. The tonic neck reflex is elicited by turning the infant's head to one side while they are lying supine, causing the limbs on the side the head is turned toward to extend, and the limbs on the opposite side to flex.

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Correct Answer is B

Explanation

A) "I will use mild soap":

Using mild soap is appropriate for newborn care as harsh soaps can irritate the baby's delicate skin. This statement indicates an understanding of proper newborn hygiene.

B) "Baby powder will help prevent a diaper rash":

This statement indicates a need for further teaching. Baby powder is no longer recommended for use on infants due to the potential inhalation risks associated with talc-based powders. Inhaling baby powder particles can cause respiratory issues and lung damage in infants. Therefore, advising against the use of baby powder would be more appropriate.

C) "I will test the water on my wrist for temperature before bathing":

Testing the water temperature before bathing is a safe practice to prevent scalding or burning the baby. This statement indicates an understanding of proper safety measures during newborn care.

D) "I will use a basin during bathing":

Using a basin during bathing is a safe and convenient way to bathe the baby, especially during the early postpartum period when the umbilical cord stump is still present. This statement indicates an understanding of proper bathing techniques for newborns.

A. A white patch on a nipple B. Red and painful area in one breast C. Cracked and bleeding nipples D. Swelling in both breasts

Correct Answer is B

Explanation

A) A white patch on a nipple:

A white patch on the nipple may indicate a condition such as a milk bleb or a fungal infection like thrush, but it is not characteristic of mastitis. Mastitis typically presents with localized redness and pain in the affected breast, along with other systemic symptoms such as fever and flu-like symptoms.

B) Red and painful area in one breast:

This finding is indicative of mastitis. Mastitis is an inflammation of the breast tissue, often caused by bacterial infection, which presents with localized redness, warmth, swelling, and pain in one breast. The affected area may also feel tender or hard to the touch.

C) Cracked and bleeding nipples:

Cracked and bleeding nipples are common in breastfeeding mothers, but they are not specific signs of mastitis. However, they can increase the risk of mastitis if bacteria enter the breast tissue through the cracked skin. Proper breastfeeding techniques and nipple care can help prevent nipple damage and reduce the risk of mastitis.

D) Swelling in both breasts:

Swelling in both breasts may occur in the early postpartum period due to engorgement or increased milk production, but it is not a specific sign of mastitis. Mastitis typically presents with localized symptoms in one breast rather than both breasts simultaneously.

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A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse should take which of the following actions?

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