When assessing a newborn, which is the best method for the nurse to use to elicit the Moro reflex?
Making a loud sound within close range of the newborn.
Firmly stroking the soles of the newborn’s feet with a thumb nail.
Using the newborn’s hands to raise the baby from a supine position without supporting the head.
Holding the newborn in an upright position so that the infant’s feet touch a cool, flat surface.
The Correct Answer is A
The correct answer is choice A. Making a loud sound within close range of the newborn will elicit the Moro reflex, which is an involuntary protective motor response against abrupt disruption of body balance or extremely sudden stimulation. The Moro reflex involves three distinct components: spreading out the arms (abduction), pulling the arms in (adduction), and crying (usually).
Choice B is wrong because firmly stroking the soles of the newborn’s feet with a thumb nail will elicit the Babinski reflex, which is a normal response in infants that involves fanning out and curling of the toes.
Choice C is wrong because using the newborn’s hands to raise the baby from a supine position without supporting the head will elicit the traction response, which is a normal response in infants that involves flexion of the elbows and shoulders.
Choice D is wrong because holding the newborn in an upright position so that the infant’s feet touch a cool, flat surface will elicit the stepping reflex, which is a normal response in infants that involves alternating steps with each foot.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. A breastfed baby is likely to gain weight more rapidly in the first month of life.This statement is wrong because breastfed babies generally gain weight faster than formula-fed babies for the first 3 months of life.They also double their birth weight by 3-4 months and triple it by one year.
Therefore, a breastfed baby’s weight gain in the first month of life is not unusual or concerning.
Choice B is correct because breastfeeding is not a reliable method of birth control.A woman can still ovulate and become pregnant while breastfeeding, especially if she feeds her baby less frequently or supplements with formula or solids.
Choice C is correct because breastfeeding has been shown to reduce the risk of allergies in babies.Breast milk contains antibodies and other immune factors that protect the baby from infections and allergic reactions.
Choice D is correct because breastfeeding mothers need to drink enough fluids to stay hydrated and produce enough milk.The recommended fluid intake for breastfeeding mothers is about 13 cups (3 liters) per day.
Correct Answer is C
Explanation
The correct answer is choice C. Ask what the patient ate and drank within the last day or two.This is because the nurse needs to assess the patient’s current nutritional status and eating habits before providing any education or advice.The nurse can then tailor the counseling to the patient’s specific needs and preferences.
Choice A is wrong because it is not the first action that the nurse should take.While it is important to explain the importance of adequate nutrition for the patient’s own growth and development, this should be done after assessing the patient’s current situation.
Choice B is wrong because it is not the first action that the nurse should take.While it is important to explain the relationship between the patient’s eating habits and fetal development, this should be done after assessing the patient’s current situation.
Choice D is wrong because it is not the first action that the nurse should take.While it is important to discuss with the patient the basic nutritional requirements of pregnancy, this should be done after assessing the patient’s current situation.
The normal ranges for nutritional intake during pregnancy vary depending on the age, weight, activity level, and health status of the patient.
However, some general guidelines are:
• Increase calorie intake by about 300 calories per day
• Increase protein intake by about 25 grams per day
• Increase calcium intake by about 1000 milligrams per day
• Increase iron intake by about 27 milligrams per day
• Increase folic acid intake by about 600 micrograms per day
• Increase fluid intake by about 8 to 10 cups per day
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