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 A
Explanation
A) 48/min:
A respiratory rate of 48 breaths per minute is within the expected reference range for a newborn. The normal range for respiratory rate in newborns is typically between 30 to 60 breaths per minute.
B) 100/min:
A respiratory rate of 100 breaths per minute is above the expected reference range for a newborn. While newborns may exhibit slightly elevated respiratory rates, a rate of 100 breaths per minute is higher than usual and may warrant further assessment.
C) 22/min:
A respiratory rate of 22 breaths per minute is below the expected reference range for a newborn. Normal respiratory rates for newborns are typically higher than 22 breaths per minute.
D) 110/min:
A respiratory rate of 110 breaths per minute is significantly above the expected reference range for a newborn. Such a high respiratory rate may indicate respiratory distress or another underlying issue and requires prompt assessment and intervention.
Correct Answer is D
Explanation
A) Notify the client's provider:
There is no indication to notify the provider at this time. The presence of lochia rubra with small clots and a firm, midline fundus at the umbilicus indicates typical postpartum bleeding and uterine involution. This finding does not warrant immediate notification of the provider.
B) Encourage the client to empty her bladder:
Encouraging the client to empty her bladder is essential for promoting uterine contractions and preventing uterine atony. However, in this scenario, the fundus is already midline and firm, suggesting that bladder distension is not the cause of the excessive bleeding. While voiding may help, it is not the priority action.
C) Increase the frequency of fundal massage:
Increasing the frequency of fundal massage may not be necessary in this situation since the fundus is already midline and firm, indicating adequate uterine contractions. Fundal massage is typically performed if the fundus is boggy or if there is excessive bleeding.
D) Document the findings and continue to monitor the client:
This is the correct action. Documenting the assessment findings, including the amount and character of lochia, presence of clots, and fundal height, is essential for ongoing monitoring and evaluation of the client's postpartum recovery. Continuing to monitor the client allows the nurse to detect any changes in condition that may require further intervention.
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