A nurse is collecting data about reflexes from a newborn. Which of the following actions should the nurse take to elicit the newborn's Moro reflex?
Perform a sharp hand clap near the infant.
Turn the newborn's head quickly to one side.
Place a finger at the base of the newborn's toes.
Hold the newborn vertically, allowing one foot to touch the crib surface.
The Correct Answer is A
Choice A rationale:
The Moro reflex, also known as the startle reflex, is a normal reflex observed in newborns. To elicit this reflex, the nurse should perform a sharp hand clap or make a loud noise near the infant. This reflex is characterized by the baby's arms and legs extending outward, followed by a quick flexion, resembling a startle response. It is an important reflex to assess the newborn's neurological and motor development.
Choice B rationale:
Turning the newborn's head quickly to one side does not elicit the Moro reflex. This action may stimulate other reflexes, such as the tonic neck reflex, but it is not the appropriate method to assess the Moro reflex.
Choice C rationale:
Placing a finger at the base of the newborn's toes does not elicit the Moro reflex. This action is more related to testing the Babinski reflex, which involves the fanning and curling of the toes when the sole of the foot is stimulated.
Choice D rationale:
Holding the newborn vertically and allowing one foot to touch the crib surface does not elicit the Moro reflex. This action might elicit the stepping reflex, where the baby shows stepping movements as if walking when held in an upright position with their feet touching a surface.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["The medical term for the soft spot on a baby's skull is fontanelle (or fontanel)."]
Explanation
The medical term for the soft spot on a baby's skull is fontanelle (or fontanel). Fontanelles are gaps between the bones of the skull that allow for the baby's brain to grow and accommodate rapid brain development during infancy. There are typically two fontanelles in a newborn's skull: the anterior fontanelle (located at the top/front of the head) and the posterior fontanelle (located at the back of the head). These fontanelles are composed of connective tissue and remain open during the early months of life, gradually closing as the baby's skull bones fuse together over time. Healthcare professionals often assess fontanelles during routine physical exams of infants. The fontanelle's size and tension can provide valuable information about the baby's hydration status, intracranial pressure, and neurological development.
Normally, the fontanelles should feel relatively soft and flat, indicating proper hydration and brain development. If the fontanelles are sunken or overly tense, it may suggest dehydration or increased intracranial pressure, which requires further evaluation and management. The proper examination of fontanelles is an essential part of newborn care, and any abnormalities observed during assessment should be promptly reported to the healthcare provider for appropriate evaluation and intervention.
Correct Answer is C
Explanation
Choice A rationale:
Reporting the client's weight to the provider is not a priority in this situation. While weight is important, the immediate concern is the newborn's respiratory distress and the acidosis indicated by the blood gases.
Choice B rationale:
Selecting diagnostic studies for the primary health care is not the nurse's role. The primary health care provider will determine which diagnostic studies are needed based on the newborn's clinical presentation and assessment findings.
Choice C rationale:
Checking brachial pulses for the client's respiratory status is the appropriate action. In a newborn with respiratory distress, assessing peripheral perfusion, including brachial pulses, is crucial to monitor the circulation and oxygenation of tissues.
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