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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "There are so many variables that you'll have to ask your obstetrician."
This response dismisses the client's question and fails to provide helpful information. While the client should discuss their specific situation with their obstetrician, the nurse should still offer some general guidance or information.
B. "The primary consideration is what type of incision was performed this time."
This is the correct response because it provides relevant information to the client's question. The type of incision made during the cesarean birth can influence the options for future deliveries. For example, a low transverse incision may make a vaginal birth after cesarean (VBAC) more likely, whereas a vertical incision might increase the likelihood of needing a repeat cesarean.
C. "A repeat cesarean birth is safer for both you and your baby."
This statement may not be accurate for all clients and situations. While repeat cesarean births are sometimes recommended for medical reasons, such as certain pregnancy complications or a previous cesarean with a vertical incision, it is not necessarily the safest option for all clients. This response also lacks consideration of the client's individual circumstances.
D. "It's too soon for you to be worrying about this now."
This response invalidates the client's concerns and fails to address their question. It's important to validate the client's feelings and provide them with accurate information to address their concerns.
Correct Answer is A
Explanation
A) "Your baby should wet 6 to 8 diapers per day":
This response is correct. One way to determine if a breastfed baby is getting enough milk is by monitoring the number of wet diapers. A newborn who is adequately breastfeeding typically wets at least 6 to 8 diapers per day, indicating sufficient fluid intake and adequate hydration.
B) "Your baby should sleep at least 6 hours between feedings":
This statement is inaccurate and does not provide an appropriate measure of whether the baby is getting enough breast milk. Newborns typically feed frequently, often every 2 to 3 hours, and it is normal for them to wake for feeds during the night. Using sleep patterns alone to assess feeding adequacy is not reliable and can lead to inadequate milk intake.
C) "Your baby should burp after each feeding":
While burping is a common practice after feeding to help prevent discomfort from trapped air, it is not an indicator of whether the baby is getting enough breast milk. Burping is more related to gastrointestinal comfort rather than feeding adequacy.
D) "Your baby should have a wake cycle of 30 to 60 minutes after each feeding":
This statement does not accurately assess feeding adequacy. While it's normal for babies to have awake periods after feeding, the duration of these wake cycles alone does not indicate whether the baby is getting enough breast milk. Monitoring diaper output and weight gain are more reliable indicators of feeding adequacy.
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