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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

This is because pregnancy-induced hypertension (PIH) can cause eclampsia, a condition characterized by seizures and coma.Eclampsia can occur during pregnancy, labor, or postpartum.

A nurse should monitor the client for signs of increased blood pressure, headache, blurred vision, epigastric pain, and hyperreflexia, which may indicate an impending convulsion.

Choice A is wrong because hemorrhage is not a common complication of PIH.

Hemorrhage may occur due to other causes such as uterine atony, lacerations, or retained placenta.

Choice B is wrong because urinary retention is not a common complication of PIH.

Urinary retention may occur due to other causes such as anesthesia, trauma, or infection.

Choice D is wrong because thrombophlebitis is not a common complication of PIH.

Thrombophlebitis is a condition where a blood clot forms in a vein and causes inflammation.

It may occur due to other risk factors such as immobility, dehydration, or injury.

A. Offer her the opportunity for counseling to help her grieve. B. Encourage the woman to hold the deceased twin as well as the living twin. C. Remind her that she should be happy that one child survived and is healthy. D. Assist the woman to take pictures of both babies.

Correct Answer is C

Explanation

The correct answer is choice C. Reminding her that she should be happy that one child survived and is healthy is the least helpful nursing action in supporting the woman as she copes with her loss.

This statement minimizes her grief and implies that she should not feel sad about the deceased twin.

It also disregards her attachment to both babies and her need to mourn the loss of one of them.

Choice A is wrong because offering her the opportunity for counseling to help her grieve is a helpful nursing action that recognizes her emotional distress and provides her with professional support.

Choice B is wrong because encouraging the woman to hold the deceased twin as well as the living twin is a helpful nursing action that allows her to acknowledge and bond with both babies and to create memories that may facilitate healing.

Choice D is wrong because assisting the woman to take pictures of both babies is a helpful nursing action that provides her with tangible mementos of her twins and honors their

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When assessing a newborn, which is the best method for the nurse to use to elicit the Moro reflex?

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Naxlex Comprehensive Predictor Exams

A client who had pregnancy-induced hypertension (PIH) is now postpartum. A nurse should closely monitor this client for which complication?

Correct Answer is C

Explanation

A woman gives birth to twin girls, one of whom is stillborn. Which nursing action would be least helpful in supporting the woman as she copes with her loss?

Correct Answer is C

Explanation

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