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 C
Explanation
Choice A rationale:
(Incorrect) The newborn with significant bruising from a face presentation is at an increased risk of elevated unconjugated bilirubin levels. Bruising can lead to the breakdown of red blood cells, increasing bilirubin production.
Choice B rationale:
(Incorrect) The premature newborn is at a higher risk of elevated unconjugated bilirubin levels. Premature infants often have an underdeveloped liver, which can lead to reduced bilirubin processing and clearance.
Choice C rationale:
(Correct) The baby born at 41 weeks' gestation is at the lowest risk for elevated unconjugated bilirubin levels. By this stage, the baby's liver is more mature, allowing for efficient processing and clearance of bilirubin.
Choice D rationale:
(Incorrect) The newborn with O+ blood type, born to a mother with O- blood type, is at an increased risk of elevated unconjugated bilirubin levels if the baby's blood type is Rh-positive and the mother's is Rh-negative. This situation can lead to Rh incompatibility and hemolytic disease of the newborn, causing higher bilirubin levels.
Correct Answer is B
Explanation
Choice A rationale:
This response would not be appropriate because it provides incorrect information. Breast milk is already present in the mother's breasts during pregnancy, and the newborn's disinterest in eating is likely due to other factors.
Choice B rationale:
This is the best response because it acknowledges the mother's concern and offers a practical solution to help the newborn latch onto the breast properly. Correct latching is crucial for successful breastfeeding, and once the baby latches on correctly, they are more likely to breastfeed effectively.
Choice C rationale:
While it is true that newborns often experience deep sleep phases, attributing the disinterest in eating solely to deep sleep is not accurate. Offering support and guidance for breastfeeding would be more beneficial.
Choice D rationale:
This response oversimplifies the situation and may not address the actual reason for the newborn's disinterest in feeding. It is essential to help the mother with proper techniques rather than just waking up the baby.
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