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 C
Explanation
This is because a normal fetal heart rate is between 110 and 160 beats per minute, and the range of 136 to 143 indicates that the fetus is well-oxygenated and not experiencing hypoxia or acidosis. The nurse should reassure the patient and explain that fetal movement may decrease during labor due to the pressure of the contractions on the uterus and the fetus.
Choice A is wrong because asking the patient about alcohol consumption is irrelevant and insensitive.
Alcohol can affect fetal development and growth, but it does not directly affect fetal movement or heart rate.
Choice B is wrong because bloody vaginal discharge, or bloody show, is a normal sign of cervical dilation and effacement during labor.
It does not indicate fetal distress or placental abruption.
Choice D is wrong because explaining the relationship between anxiety and fetal movement does not address the patient’s concern or provide any factual information.
Anxiety can affect maternal perception of fetal movement, but it does not cause fetal movement to decrease.
The nurse should validate the patient’s feelings and provide factual reassurance.
Correct Answer is B
Explanation
The correct answer is choice B. Taking mineral oil each night is not recommended for pregnant women who have hemorrhoids because it can interfere with the absorption of fat-soluble vitamins and cause diarrhea, which can worsen hemorrhoids.
The patient should avoid laxatives and stool softeners unless prescribed by a health care provider.
Choice A is wrong because walking at least a mile a day can help improve blood circulation and prevent constipation, which are both beneficial for hemorrhoid management.
Choice C is wrong because including foods high in fiber in the diet can help soften stools and prevent straining, which can aggravate hemorrhoids.
Choice D is wrong because drinking one extra glass of water before breakfast each morning can help hydrate the body and prevent dehydration, which can cause hard stools and increase pressure on the anal veins.
The nurse should teach the patient other strategies for hemorrhoid management, such as applying ice packs or witch hazel pads to the affected area, using sitz baths or warm water baths, avoiding prolonged sitting or standing, and wearing cotton underwear.
The nurse should also advise the patient to report any signs of infection or bleeding to the health care provider.
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