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: "If I go too long overdue, the amniotic ﬂuid volume can become too low for my baby to be safe." This is a correct answer that indicates that the client understands one of the Reasons for induction of labor at 42 weeks' pregnancy.

Choice B Reason: "My baby took longer to grow, and now she's ready to be born." This is an incorrect answer that shows a misconception about fetal growth and development. Fetal growth does not depend on gestational age alone, but also on genetic, maternal, placental, and environmental factors. A post-term fetus does not necessarily grow faster or larger than a term fetus. In fact, some post-term fetuses may experience intrauterine growth restriction (IUGR), which means slower than expected growth for gestational age.

Choice C Reason: "I don't really need this induction, my baby will come whenever he wants to." This is an incorrect answer that reveals a lack of awareness or acceptance of the need for induction of labor at 42 weeks' pregnancy. Induction of labor is recommended for post-term pregnancies to prevent potential complications such as fetal distress, stillbirth, or maternal hemorrhage.

Choice D Reason: "Since I am so tired of being pregnant, I am being induced." This is an incorrect answer that implies that induction of labor is based on maternal preference or convenience rather than medical indication. Induction of labor should not be done without a valid Reason or informed consent, as it carries some risks such as failed induction, prolonged labor, infection, uterine rupture, or cesarean delivery.

A. Contact the physician, as it indicates early DIC. B. Contact the physician, as it is a first sign of postpartum eclampsia. C. Document the finding as it is a normal finding at this time. D. Obtain an order for a CBC, as it suggests postpartum anemia.

Correct Answer is C

Explanation

Choice A Reason: Contact the physician, as it indicates early DIC. This is an incorrect answer that confuses a low pulse rate with a high pulse rate. DIC stands for disseminated intravascular coagulation, which is a life-threatening condition where abnormal clotting and bleeding occur simultaneously in the body. DIC can occur as a complication of postpartum hemorrhage, infection, or placental abruption. DIC can cause tachycardia (high pulse rate), not bradycardia (low pulse rate).

Choice B Reason: Contact the physician, as it is a first sign of postpartum eclampsia. This is an incorrect answer that misinterprets a low pulse rate as a sign of hypertension. Postpartum eclampsia is a condition where seizures occur in a woman who has preeclampsia or eclampsia after delivery. Preeclampsia and eclampsia are characterized by high blood pressure and proteinuria in pregnancy. Postpartum eclampsia can cause hypertension (high blood pressure), not hypotension (low blood pressure).

Choice C Reason: Document the finding as it is a normal finding at this time. This is because a pulse rate of 60 beats per minute is within the normal range for an adult and may reﬂect a physiological adaptation to the postpartum period. During pregnancy, the maternal blood volume and cardiac output increase, which can elevate the pulse rate. After delivery, these parameters gradually return to pre-pregnancy levels, which can lower the pulse rate.

Choice D Reason: Obtain an order for a CBC, as it suggests postpartum anemia. This is an incorrect answer that assumes that a low pulse rate is caused by anemia. Anemia is a condition where the red blood cell count or hemoglobin level is lower than normal, which can impair oxygen delivery to the tissues. Anemia can occur in the postpartum period due to blood loss during delivery or poor nutritional intake during pregnancy. Anemia can cause tachycardia (high pulse rate), not bradycardia (low pulse rate).

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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

The client at 42 weeks' pregnancy is admited for induction of her labor. Which statement indicates that she understands the Reasons for the induction? Select one:

Correct Answer is A

Explanation

A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 60 beats per minute. Which of these actions should the nurse take? Select one:

Correct Answer is C

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: