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 their abdomen and observe the movement of their extremities.
Stroke the newborn’s cheek toward their mouth.
Stroke upward on the lateral aspect of the newborn’s foot.
Place the newborn on a flat surface and clap hands loudly.
The Correct Answer is D
Place the newborn on a flat surface and clap hands loudly.
This action will elicit the Moro reflex, also known as the startle reflex, which is a normal, involuntary reaction that newborns and infants have when they’re startled. In response to the sound, the baby will throw back his or her head, extend out his or her arms and legs, cry, then pull the arms and legs back in.
Choice A is wrong because placing the newborn on their abdomen and observing the movement of their extremities will not trigger the Moro reflex.
This position may elicit other reflexes such as the crawling reflex or the tonic neck reflex.
Choice B is wrong because stroking the newborn’s cheek toward their mouth will not trigger the Moro reflex. This action will elicit the rooting reflex, which helps the baby find the breast or bottle to start feeding.
Choice C is wrong because stroking upward on the lateral aspect of the newborn’s foot will not trigger the Moro reflex. This action will elicit the Babinski reflex, which causes the big toe to extend upward and the other toes to fan out.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
“I will not play soccer until my doctor tells me I can.” This statement indicates that the client understands the risk of splenic rupture due to splenomegaly and the need to avoid contact sports until the spleen returns to normal size.
Choice A is wrong because antibiotics are not effective for infectious mononucleosis, which is caused by a virus.
Choice C is wrong because varicella booster is not related to infectious mononucleosis and there is no evidence that the client needs it.
Choice D is wrong because jaundice (yellowing of the eyes and skin) is not a common manifestation of infectious mononucleosis and may indicate another condition such as hepatitis.
Normal ranges for spleen size are 7 to 14 cm in length and 3 to 4 cm in thickness.
Correct Answer is D
Explanation
Insulin lispro was administered to a client immediately before bed. This is a situation that requires the completion of an incident report because insulin lispro is a rapid-acting insulin that should be given within 15 minutes before or after a meal. Giving it immediately before bed can cause hypoglycemia (low blood sugar) during the night, which can be dangerous for the client.
Choice A is wrong because nitroglycerin transdermal is a medication used to prevent angina (chest pain) and can be applied to a client’s chest as prescribed.
Choice B is wrong because cefotaxime is an antibiotic that can be administered to a client after obtaining blood cultures to treat an infection.
Choice C is wrong because digoxin is a medication used to treat heart failure and atrial fibrillation and can be administered to a client who has a heart rate of 64/min, which is within the normal range of 60 to 100 beats per minute.
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