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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

BMI 32.2.

A high body mass index (BMI) is a major risk factor for type 2 diabetes mellitus, as it indicates overweight or obesity.

Overweight or obesity can cause insulin resistance, which means the body cells do not respond well to insulin and cannot take up glucose from the blood. This leads to high blood sugar levels and diabetes.

Choice A is wrong because history of exercise-induced asthma is not a risk factor for type 2 diabetes mellitus.

Asthma is a respiratory condition that causes inflammation and narrowing of the airways, but it does not affect the metabolism of glucose or insulin.

Choice B is wrong because age 35 years is not a risk factor for type 2 diabetes mellitus.

Although the risk of diabetes increases with age, especially after 45 years, it can also occur in younger people.

Age alone is not enough to cause diabetes.

Choice C is wrong because history of mumps is not a risk factor for type 2 diabetes mellitus.

Mumps is a viral infection that affects the salivary glands, but it does not damage the pancreas or impair insulin production.

Some other risk factors for type 2 diabetes mellitus are family history, race or ethnicity, physical inactivity, prediabetes, gestational diabetes, polycystic ovarian syndrome, and smoking.

A. “I’m urinating in larger amounts.” B. “I have to sleep sitting up.” C. “I suck on hard candy for my dry mouth.” D. “I’ve lost 3 pounds in the last week.”

Correct Answer is B

Explanation

This statement indicates that the client has orthopnea, which is a sign of worsening heart failure and fluid overload. The nurse should intervene by assessing the client’s vital signs, oxygen saturation, lung sounds, and edema, and notifying the provider for possible diuretic adjustment.

Choice A is wrong because “I’m urinating in larger amounts.” is an expected outcome of taking furosemide, which is a loop diuretic that increases urine output and reduces fluid retention.

Choice C is wrong because “I suck on hard candy for my dry mouth.” is a harmless way to cope with the side effect of dry mouth caused by furosemide.

Choice D is wrong because “I’ve lost 3 pounds in the last week.” is a positive sign that the client is losing excess fluid and improving their heart failure

condition. A weight loss of 2 to 4 pounds per week is acceptable for clients taking diuretics.

Normal ranges for heart failure clients are:

Blood pressure: less than 140/90 mmHg
Heart rate: 60 to 100 beats per minute
Respiratory rate: 12 to 20 breaths per minute
Oxygen saturation: greater than 95%
Weight: stable or decreasing within 2 to 4 pounds per week

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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?

Nursing Test Bank

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Correct Answer is D

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Correct Answer is B

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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?