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 B

Explanation

Massaging the uterus helps it contract and prevent excessive bleeding after delivery.Uterine atony is a condition where the uterus does not contract enough to clamp the blood vessels that supply the placenta, leading to postpartum hemorrhage.Uterine massage is one of the interventions to treat uterine atony and restore uterine tone.

Choice A is wrong because having the client void frequently does not directly affect the uterine contraction.However, a full bladder can interfere with uterine contraction and cause displacement of the uterus, so it is important to monitor the bladder status and empty it as needed.

Choice C is wrong because having the client in a side-lying position for comfort does not help with uterine contraction.However, this position may be beneficial for other reasons, such as reducing edema and pain in the perineal area.

Choice D is wrong because keeping the patient on strict bed rest for 24 hours to avoid stress on the uterus does not help with uterine contraction.In fact, early ambulation after delivery can help prevent thromboembolic complications and promote recovery.

Normal ranges for postpartum blood loss are less than 500 mL for vaginal delivery and less than 1000 mL for cesarean delivery.Postpartum hemorrhage is defined as blood loss greater than or equal to 1000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after birth.

A. Elevate the head of the infant’s crib. B. Apply a water-soluble ointment to the infant’s eyes. C. Dress the infant in a long-sleeved shirt. D. Keep the infant well hydrated.

Correct Answer is D

Explanation

he correct answer is choice D. Keep the infant well hydrated.This is because phototherapy can cause dehydration due to increased insensible water loss from the skin.Hydration helps the infant excrete bilirubin in urine and stool.

Choice A is wrong because elevating the head of the infant’s crib does not affect bilirubin levels or phototherapy effectiveness.

Choice B is wrong because applying a water-soluble ointment to the infant’s eyes can interfere with eye protection and cause eye irritation.The infant’s eyes should be covered with opaque patches or goggles during phototherapy to prevent eye damage.

Choice C is wrong because dressing the infant in a long-sleeved shirt reduces the amount of skin exposed to light and decreases the efficacy of phototherapy.The infant should be undressed except for a diaper and eye protection during phototherapy.

Normal ranges for bilirubin levels vary depending on the age of the infant, the type of jaundice, and the method of measurement.Generally, bilirubin levels above 25 mg/dL are considered dangerous and require urgent treatment.

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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

The nurse is assigned to care for the postpartum client during her shift. The nurse knows one of the most common risk factors for early (PPH) postpartum hemorrhage is uterine atony. When providing care, the nurse would plan to:.

Correct Answer is B

Explanation

A newborn develops hyperbilirubinemia when 24 hours old and is prescribed phototherapy. Which measure is an important part of this newborn’s care plan?

Correct Answer is D

Explanation

A nurse is caring for a patient being evaluated for sexually transmitted infection (STI).A negative rapid plasma reagin (RPR) indicates that a patient is probably not infected with which STI?

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A patient who is 42 weeks pregnant is admitted to the hospital in active labor.The patient is upset and says to the nurse, "I haven't felt the baby move for about three or four hours." The fetal heart rate is ranging between 136 and 143. Which action should the nurse take?

A nurse is reviewing laboratory results of a pregnant patient.Which result will require further assessment?

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

The nurse provides a 16-year-old client with information concerning expected and possible changes during pregnancy. Which statement, if made by the client, would indicate that she understands the information?

The nurse prepares to counsel a 14-year-old patient who is 16 weeks pregnant regarding nutrition. Which action would be appropriate for the nurse to take first?

A client who is 22 weeks pregnant with a twin gestation comes to the clinic. The nurse instructs the client in self-care for the third trimester of pregnancy. Which statement made by the client would indicate the need for further teaching?