A nurse is checking a newborn's Moro reflex. Which of the following actions should the nurse take to elicit this reflex?

Place the newborn on a flat surface and clap hands loudly.

Stroke the newborn's cheek toward their mouth.

Stroke upward on the lateral aspect of the newborn's foot.

Place the newborn on their abdomen and observe the movement of their extremities.

Answer and Explanation

The Correct Answer is A

A. Place the newborn on a flat surface and clap hands loudly:
A sudden loud noise or movement causes the newborn to extend and abduct arms, then adduct them – the Moro (startle) reflex.

B. Stroke the newborn's cheek toward their mouth:
This tests the rooting reflex, not the Moro reflex.

C. Stroke upward on the lateral aspect of the newborn's foot:
This elicits the Babinski reflex, not Moro.

D. Place the newborn on their abdomen and observe the movement of their extremities:
This would assess gross motor tone or posture, not the Moro reflex.

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Correct Answer is B

Explanation

A. 60 mL catheter-tip syringe
More appropriate for enteral tube feeding, not general dysphagia management.

B. Yankauer suction device
Needed in case the client aspirates or has trouble managing oral secretions.

C. pH strip
Used to verify placement of NG tubes, not specific to dysphagia precautions.

D. Padded tongue blade
Used for seizure precautions-not relevant here unless seizure risk exists.

A. Document the client's mood and affect. B. Search the client's personal belongings. C. Attend an interdisciplinary team meeting. D. Assign the client to a semi-private room.

Correct Answer is B

Explanation

A. Document the client’s mood and affect.
Important, but not the first action.

B. Search the client’s personal belongings.
Safety comes first. The priority is removing any items that could be used for self-harm.

C. Attend an interdisciplinary team meeting.
Will occur later-client’s immediate safety takes priority.

D. Assign the client to a semi-private room.
Private rooms are preferred to allow better monitoring and safety checks.

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A nurse is checking a newborn's Moro reflex. Which of the following actions should the nurse take to elicit this reflex?

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