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 D

Explanation

Choice A Reason: Hyperglycemia and increased appetite. This is an incorrect answer that describes symptoms of diabetes mellitus, not sepsis. Diabetes mellitus is a chronic metabolic disorder where the body cannot produce or use insulin eﬀectively, which results in high blood glucose levels and impaired glucose tolerance. Diabetes mellitus can aﬀect newborns if the mother has pre-existing or gestational diabetes, which can cause macrosomia, hypoglycemia, or congenital anomalies.

Choice B Reason: Increased urinary output and spitting up mucous. This is an incorrect answer that indicates normal or benign conditions, not sepsis. Increased urinary output is a normal finding in newborns, as they eliminate the excess ﬂuid that was accumulated during pregnancy. Spitting up mucous is a common occurrence in newborns, as they clear their airways of amniotic ﬂuid or secretions.

Choice C Reason: Wakefulness and ruddy appearance. This is an incorrect answer that suggests healthy or normal characteristics, not sepsis. Wakefulness is a sign of alertness and responsiveness in newborns, which reﬂects their neurological development and adaptation. Ruddy appearance is a reddish color of the skin that is normal in newborns, especially in term or post-term infants, which indicates adequate oxygenation and hemoglobin levels.

Choice D Reason: Temperature instability and lethargy. This is because temperature instability and lethargy are common signs of sepsis in newborns, which indicate systemic infection and inﬂammation. Sepsis is a life-threatening condition where the body's response to infection causes tissue damage, organ failure, or death. Sepsis can occur in newborns due to maternal, fetal, or neonatal factors, such as chorioamnionitis, premature rupture of membranes, prolonged labor, invasive procedures, or bacterial colonization.

A. Macrosomic fetus. B. Preeclampsia. C. Inadequate nutritional status of mother. D. Cephalopelvic disproportion.

Correct Answer is A

Explanation

Choice A Reason: Macrosomic fetus is a fetus that weighs more than 4000 grams or 8 pounds 13 ounces at birth. It is not a common complication of teenage pregnancy, but rather of maternal diabetes, obesity, or a history of large babies.

Choice B Reason: Preeclampsia is a condition characterized by high blood pressure and proteinuria in pregnancy. It can cause serious complications for both the mother and the baby, such as seizures, organ damage, growth restriction, and placental abruption. Teenage pregnancy is a risk factor for preeclampsia, especially if the mother is younger than 15 years old.

Choice C Reason: Inadequate nutritional status of mother is a condition where the mother does not consume enough calories, protein, vitamins, minerals, or ﬂuids during pregnancy. It can aﬀect the growth and development of the baby and increase the risk of low birth weight, preterm birth, and birth defects. Teenage pregnancy is a risk factor for inadequate nutritional status of mother, as teenagers may have poor dietary habits, eating disorders, or limited access to food.

Choice D Reason: Cephalopelvic disproportion is a condition where the size or shape of the baby's head or body is too large to fit through the mother's pelvis. It can prevent normal vaginal delivery and require cesarean section. Teenage pregnancy is a risk factor for cephalopelvic disproportion, as teenagers may have smaller or immature pelvises that are not fully developed.

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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 D

Explanation

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Correct Answer is A

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: