Exhibits

A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse take?

Measure the abdominal circumference at the level of the newborn's umbilicus every 12 hr.

Insert an orogastric decompression tube with low wall suction.

Provide the newborn with an iron-rich formula containing vitamin B12 every 2 hr.

Administer nitric oxide inhalation therapy to the newborn.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Measuring the abdominal circumference at the level of the newborn's umbilicus every 12 hr is a critical action in this scenario. The newborn has necrotizing enterocolitis (NEC), a serious gastrointestinal condition, and measuring abdominal circumference can help monitor for changes in abdominal distention, which is a sign of NEC progression.

Choice B rationale:

Inserting an orogastric decompression tube with low wall suction may not be the most appropriate action for a newborn with NEC. While decompression tubes can be used in some cases of NEC, their insertion should be guided by specific clinical indications, and not all cases require them.

Choice C rationale:

Providing the newborn with an iron-rich formula containing vitamin B12 every 2 hr is not indicated for NEC. NEC requires specialized medical management and treatment, which may include bowel rest and other interventions, but providing iron-rich formula is not one of them.

Choice D rationale:

Administering nitric oxide inhalation therapy is not relevant to the management of NEC. Nitric oxide inhalation therapy is used for respiratory conditions, particularly persistent pulmonary hypertension of the newborn, and does not address the gastrointestinal issues seen in NEC.

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Correct Answer is A

Explanation

Choice A rationale:

The Moro reflex, also known as the startle reflex, is elicited by making a loud noise above the newborn, causing them to extend their arms and legs and then bringing them back to the body in a hugging motion. This reflex is a normal developmental response in term newborns.

Choice B rationale:
Touching the newborn's cheek with a finger elicits the rooting reflex, where the newborn turns their head toward the stimulus, searching for a nipple or object to suck. It is a different reflex and not the Moro reflex.

Choice C rationale:
Tapping the newborn's forehead with a finger does not elicit any specific reflex. This action is not related to the Moro reflex.

Choice D rationale:
Turning the newborn's head to one side elicits the asymmetric tonic neck reflex (ATNR), not the Moro reflex. In ATNR, when the head is turned to one side, the arm on that side extends while the opposite arm flexes.

A. Increased fetal movement. B. Increased urinary output. C. Increased muscle weakness. D. Increased respiratory rate.

Correct Answer is C

Explanation

Choice A rationale:
Increased fetal movement is a positive sign during pregnancy and indicates the well-being of the baby. It is not a concern and does not require reporting.

Choice B rationale:
Increased urinary output may be expected in a client receiving magnesium sulfate due to its diuretic effects. This finding is not alarming and does not require immediate reporting unless it is associated with other concerning symptoms.

Choice C rationale:
Increased muscle weakness is a potential side effect of magnesium sulfate administration. It is important to monitor the client for signs of magnesium toxicity, and increased muscle weakness should be reported promptly as it may indicate the need for adjustments in the dosage or administration of the medication.

Choice D rationale:
Increased respiratory rate is not typically associated with magnesium sulfate use and is unlikely to be a concerning finding in this context. However, it's always essential to monitor respiratory status, but it may not be specifically related to the magnesium sulfate treatment.

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Exhibits A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing the reflexes of a term newborn. After placing the newborn in the supine position, which of the following methods should the nurse use to elicit the Moro reflex?

Correct Answer is A

Explanation

A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. Which of the following clinical findings should the nurse instruct the client to report?

Correct Answer is C

Explanation

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Exhibits

A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse take?