The nurse is performing a newborn physical assessment and is about to elicit the Moro reﬂex. Which of the following responses should the nurse expect to see?
Select one:

The cheek of the newborn is touched, and the newborn turns toward the side that was touched.

The newborn is suddenly lowered or startled, and they extend their arms, legs and neck, then rapidly bring their arms together.

The newborn is supine and their head is turned to one side, then the arm on that same side extends.

The lateral aspect of the sole of the newborn's foot is stroked, and the toes extend and fan outward.

Answer and Explanation

The Correct Answer is B

Choice A Reason: The cheek of the newborn is touched, and the newborn turns toward the side that was touched. This is an incorrect answer that describes a diﬀerent reﬂex called the rooting reﬂex. The rooting reﬂex is a feeding reﬂex that helps the newborn locate the nipple and initiate sucking. The rooting reﬂex is elicited by stroking the cheek or corner of the mouth of the newborn, which causes them to turn their head and open their mouth toward the stimulus.

Choice B Reason: The newborn is suddenly lowered or startled, and they extend their arms, legs and neck, then rapidly bring their arms together. This is because this response describes the Moro reﬂex, which is a primitive reﬂex that is present at birth and disappears by 3 to 6 months of age. The Moro reﬂex is elicited by simulating a falling sensation or a loud noise, which triggers a fear response in the newborn. The Moro reﬂex consists of four phases: extension, abduction, adduction, and crying.

Choice C Reason: The newborn is supine and their head is turned to one side, then the arm on that same side extends. This is an incorrect answer that refers to another reﬂex called the tonic neck reﬂex. The tonic neck reﬂex is a postural reﬂex that helps prepare the newborn for voluntary reaching. The tonic neck reﬂex is elicited by placing the newborn in a supine position and turning their head to one side, which causes them to assume a "fencing" posture with one arm extended and one arm ﬂexed.

Choice D Reason: The lateral aspect of the sole of the newborn's foot is stroked, and the toes extend and fan outward. This is an incorrect answer that indicates a diﬀerent reﬂex called the Babinski reﬂex. The Babinski reﬂex is a neurological reﬂex that tests for spinal cord integrity. The Babinski reﬂex is elicited by stroking the lateral aspect of the sole of the foot from heel to toe, which causes the big toe to dorsiﬂex and the other toes to fan out.

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Correct Answer is A

Explanation

Choice A Reason: Latent phase of the first stage of labor. This is because this phase is characterized by mild and irregular contractions, slow cervical dilation (up to 4 cm), minimal cervical eﬀacement (up to 40%), and minimal discomfort or pain. The latent phase is also known as the early phase or preparatory phase of labor.

Choice B Reason: Transition phase of the first stage of labor. This is an incorrect answer that describes a diﬀerent phase with diﬀerent characteristics. The transition phase is marked by strong and frequent contractions, rapid cervical dilation (from 8 to 10 cm), complete cervical eﬀacement (100%), and intense discomfort or pain. The transition phase is also known as the terminal phase or acceleration phase of labor.

Choice C Reason: Perineal phase of the second stage of labor. This is an incorrect answer that refers to another stage and phase with diﬀerent features. The second stage of labor begins with complete cervical dilation (10 cm) and ends with delivery of the baby. The perineal phase is the last part of the second stage, where the baby's head crowns and emerges through the vaginal opening.

Choice D Reason: Active phase of the first stage of labor. This is an incorrect answer that indicates another phase with diﬀerent atributes. The active phase is characterized by moderate and regular contractions, progressive cervical dilation (from 4 to 8 cm), increased cervical eﬀacement (from 40% to 80%), and increased discomfort or pain. The active phase is also known as the middle phase or dilatation phase of labor.

A. Applying Vaseline or lotion to newborn to maximize light absorption. B. Reducing the amount of ﬂuid intake to 8 ounces daily. C. Keeping the newborn in the supine position. D. Feeding every 3 hours to maximize intake of ﬂuids and output.

Correct Answer is D

Explanation

Choice A Reason: Applying Vaseline or lotion to newborn to maximize light absorption. This is an incorrect answer that indicates a contraindicated and harmful intervention that can interfere with phototherapy. Applying Vaseline or lotion to newborn can create a barrier or a reﬂective surface that can reduce the exposure and penetration of light to the skin, which can decrease the efficacy of phototherapy. Applying Vaseline or lotion to newborn can also cause skin irritation, infection, or burns, as it can trap heat and moisture under the light source.

Choice B Reason: Reducing the amount of ﬂuid intake to 8 ounces daily. This is an incorrect answer that suggests a detrimental and dangerous intervention that can impair phototherapy. Reducing the amount of ﬂuid intake to 8 ounces daily can cause dehydration, hypoglycemia, or electrolyte imbalance in newborns, which can worsen jaundice and increase the risk of complications such as kernicterus (brain damage due to high bilirubin levels). Reducing the amount of ﬂuid intake to 8 ounces daily can also decrease the excretion of bilirubin through urine or stool, which can counteract the eﬀect of phototherapy.

Choice C Reason: Keeping the newborn in the supine position. This is an incorrect answer that implies an incomplete and inadequate intervention that can limit phototherapy. Keeping the newborn in the supine position is a nursing action that involves placing the newborn on their back, which can expose their anterior body surface to light.

However, keeping the newborn in the supine position alone is not sufficient for phototherapy, as it does not expose their posterior body surface to light. The nurse should also reposition the newborn frequently to expose diﬀerent body parts to light, such as their sides or abdomen.

Choice D Reason: Feeding every 3 hours to maximize intake of ﬂuids and output. This is because feeding every 3 hours is a nursing intervention that can enhance the eﬀectiveness and safety of phototherapy, which is a treatment that uses blue or white light to reduce the level of bilirubin in the blood. Bilirubin is a yellow pigment that is produced when red blood cells are broken down, which can cause jaundice (yellowish discoloration of the skin and mucous membranes) if it accumulates in excess. Phototherapy works by converting bilirubin into a water-soluble form that can be excreted through urine or stool. Feeding every 3 hours can increase the intake of ﬂuids and calories, which can promote hydration, nutrition, and elimination of bilirubin.

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The nurse is performing a newborn physical assessment and is about to elicit the Moro reﬂex. Which of the following responses should the nurse expect to see? Select one:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Which of the following would the nurse include in the plan of care for a newborn receiving phototherapy? Select one:

Correct Answer is D

Explanation

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The nurse is performing a newborn physical assessment and is about to elicit the Moro reﬂex. Which of the following responses should the nurse expect to see?
Select one: