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 D

Explanation

A) Moro reflex:

The Moro reflex is a startle reflex characterized by the newborn's arms and legs extending outward in response to a sudden movement or noise. It is not involved in promoting breastfeeding latching.

B) Babinski reflex:

The Babinski reflex is a reflex action of the newborn's foot in response to stimulation. It involves the toes spreading out and the big toe dorsiflexing when the sole of the foot is stroked. This reflex is unrelated to breastfeeding.

C) Stepping reflex:

The stepping reflex is an automatic response seen in newborns when held upright with their feet touching a solid surface. They make stepping movements with their legs as if they are walking. This reflex is unrelated to breastfeeding.

D) Rooting reflex:

The rooting reflex is a natural instinct in newborns characterized by turning their head toward a stimulus that strokes or touches their cheek or mouth. This reflex helps facilitate breastfeeding by guiding the newborn's mouth toward the nipple, making it easier for them to latch onto the breast and initiate feeding.

A. Ask the client to rate her pain. B. Encourage the client to perform Kegel exercises. C. Assist the client to the bathroom to void. D. Encourage the client to move to the left lateral position.

Correct Answer is C

Explanation

A) Ask the client to rate her pain:

Assessing the client's pain is important for overall postpartum care, but it does not directly address the issue of a slightly boggy and displaced fundus. Pain assessment should be done routinely but is not the priority in this situation.

B) Encourage the client to perform Kegel exercises:

Kegel exercises are beneficial for strengthening pelvic floor muscles but do not address the issue of a boggy and displaced fundus. While Kegel exercises can promote postpartum recovery, they are not the priority intervention in this case.

C) Assist the client to the bathroom to void:

This is the correct action. A boggy and displaced fundus may indicate urinary retention, which can contribute to uterine atony. Helping the client to the bathroom to void can relieve bladder distension, allowing the uterus to contract more effectively and reducing the risk of postpartum hemorrhage.

D) Encourage the client to move to the left lateral position:

Moving to the left lateral position can help improve uterine perfusion by relieving pressure on the vena cava, but it does not directly address the issue of urinary retention or a boggy fundus. While changing positions is generally beneficial postpartum, assisting the client to void takes precedence in this situation to address the potential cause of uterine atony.

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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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