A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse should take which of the following actions?
Place a finger at the base of the newborn’s toes.
Turn the newborn’s head quickly to one side.
Hold the newborn vertically allowing one foot to touch the table surface.
Perform a sharp hand clap near the infant.
The Correct Answer is D
Choice A reason:
Placing a finger at the base of the newborn’s toes is used to elicit the Babinski reflex, not the Moro reflex. The Babinski reflex is observed when the toes fan out and the big toe moves upward in response to stroking the sole of the foot1. This reflex is a normal finding in infants up to 2 years old and indicates normal neurological development.
Choice B reason:
Turning the newborn’s head quickly to one side is used to elicit the tonic neck reflex, also known as the “fencing” reflex. When the head is turned to one side, the arm on that side extends while the opposite arm bends at the elbow, resembling a fencing position2. This reflex is typically present from birth to about 6 months of age.
Choice C reason:
Holding the newborn vertically and allowing one foot to touch the table surface is used to elicit the stepping reflex. When the baby’s foot touches a surface, they will make stepping movements as if trying to walk3. This reflex is usually present from birth until about 2 months of age.
Choice D reason:
Performing a sharp hand clap near the infant is a method to elicit the Moro reflex, also known as the startle reflex. The Moro reflex is triggered by a sudden loud noise or a sensation of falling. The infant will respond by extending and abducting the arms, opening the hands, and then bringing the arms back to the body. This reflex is present at birth and typically disappears by 4 to 6 months of age.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
The indirect Coombs test is used to detect Rh-positive antibodies in the mother’s blood. This test is crucial for Rh-negative mothers who have given birth to Rh-positive infants. It helps determine if the mother has been sensitized to Rh-positive blood and has developed antibodies against it. If these antibodies are present, they can cross the placenta in future pregnancies and attack the red blood cells of an Rh-positive fetus, leading to hemolytic disease of the newborn.
Choice B reason:
The statement “It determines the presence of maternal antibodies in the newborn’s blood” is incorrect. The indirect Coombs test is performed on the mother’s blood, not the newborn’s. It screens for antibodies that could potentially harm the fetus in future pregnancies. The direct Coombs test, on the other hand, is used to detect antibodies that are already attached to the newborn’s red blood cells.
Choice C reason:
The statement “It detects Rh-negative antibodies in the newborn’s blood” is incorrect. The indirect Coombs test does not detect Rh-negative antibodies in the newborn’s blood. Instead, it identifies antibodies in the mother’s blood that could react against Rh-positive red blood cells. This test helps in assessing the risk of hemolytic disease in future pregnancies.
Choice D reason:
The statement “It determines if kernicterus will occur in the newborn” is incorrect. Kernicterus is a severe form of jaundice caused by high levels of bilirubin in the blood. While the Coombs test can help identify hemolytic disease, which can lead to jaundice, it does not directly determine the risk of kernicterus. The primary purpose of the indirect Coombs test is to detect antibodies that could cause hemolytic disease in future pregnancies.
Correct Answer is A
Explanation
Choice A reason:
Dyspnea: Dyspnea, or difficulty breathing, is a serious adverse effect that should be reported immediately. Terbutaline can cause pulmonary edema, a condition where fluid accumulates in the lungs, leading to severe breathing difficulties. This side effect is critical and requires prompt medical attention to prevent further complications.
Choice B reason:
Headaches: While headaches are a common side effect of terbutaline, they are generally not considered severe enough to require immediate reporting unless they are persistent or unusually intense. Headaches can be managed with over-the-counter pain relief and do not typically indicate a serious problem.
Choice C reason:
Nervousness: Nervousness is another common side effect of terbutaline. It is usually mild and does not require immediate medical intervention. However, if the nervousness is severe or accompanied by other symptoms, it should be discussed with a healthcare provider.
Choice D reason:
Tremors: Tremors are a known side effect of terbutaline and are usually not severe. They occur due to the medication’s action on the nervous system. While they can be bothersome, they are not typically dangerous and do not require urgent reporting unless they are severe or persistent.
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