When the newborn's crib was moved suddenly, the nurse noticed that his legs flexed and the arms fanned out, and then both came back toward the midline. The nurse would interpret this behavior as:

The Moro reflex was elicited.

This is abnormal for a full-term infant.

There may be an abnormality in the musculoskeletal system.

The full-term infant should not react to sudden movement.

Answer and Explanation

The Correct Answer is A

The Moro reflex was elicited. This is because the Moro reflex is a normal newborn reflex that occurs when the baby is startled by a loud noise or a sudden movement. The baby responds by extending the arms and legs, opening the hands, and then bringing the arms and legs back to the chest.

The Moro reflex is present at birth and disappears by 3 to 6 months of age.

Choice B is wrong because this is not abnormal for a full-term infant. The Moro reflex is a sign of a healthy nervous system and brain development.

Choice C is wrong because there is no evidence of an abnormality in the musculoskeletal system. The Moro reflex does not indicate any problems with the bones or muscles of the baby.

Choice D is wrong because the full-term infant should react to sudden movement. The Moro reflex is a protective response that helps the baby cling to the mother in case of danger.

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Correct Answer is C

Explanation

Administer low concentrations of oxygen. Retinopathy of prematurity (ROP) is a disease of retinal vascular and capillary proliferation affecting premature infants undergoing oxygen therapy. Oxygen treatment results in pathologic growth of vessels in the developing retina that may lead to permanent damage to the retina as well as retinal detachment and macular folds. Administering low concentrations of oxygen can help prevent ROP by reducing the oxygen-induced vasoconstriction and vascular endothelial growth factor (VEGF) expression.

Choice A is not correct because keeping the infant's eyes covered at all times does not prevent ROP. In fact, it may increase the risk of infection or injury to the eyes.

Choice B is not correct because positioning with the head slightly lower than the body does not prevent ROP. It may increase the intracranial pressure and affect the cerebral blood flow.

Choice D is not correct because monitoring arterial oxygen levels with a pulse oximeter does not prevent ROP. It is a useful tool to guide oxygen therapy, but it does not directly affect retinal vascular development.

A. Gentle massage of the affected leg B. Anticoagulants for 6 weeks C. Passive leg exercises twice a day D. Application of ice to the affected leg

Correct Answer is B

Explanation

Anticoagulants for 6 weeks. This is because the client’s symptoms suggest that she has deep vein thrombosis (DVT), which is a blood clot in a deep vein of the leg. DVT is a serious condition that can lead to pulmonary embolism, which is a blockage of a blood vessel in the lungs. The treatment for DVT involves anticoagulants, which are drugs that prevent blood clots from growing or forming new ones. The duration of anticoagulant therapy depends on the risk factors and severity of DVT, but it is usually at least 6 weeks.

Choice A is wrong because gentle massage of the affected leg can dislodge the clot and cause a pulmonary embolism.

Choice C is wrong because passive leg exercises can increase blood flow and worsen pain and swelling.

Choice D is wrong because the application of ice to the affected leg can reduce inflammation but does not treat the underlying clot.

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When the newborn's crib was moved suddenly, the nurse noticed that his legs flexed and the arms fanned out, and then both came back toward the midline. The nurse would interpret this behavior as:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To prevent possible retinopathy in a preterm infant requiring oxygen therapy, the nurse will:

Correct Answer is C

Explanation

During a postpartum assessment, a woman reports that her right calf is painful. The nurse observes edema and redness along the saphenous vein in the right lower leg. Based on this finding, the nurse explains that the probable treatment will involve:

Correct Answer is B

Explanation

A nurse is collecting data from a newborn and notes a swollen area on the head that does not cross the suture line. The nurse should interpret this finding as which of the following?

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The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature.

When the newborn's crib was moved suddenly, the nurse noticed that his legs flexed and the arms fanned out, and then both came back toward the midline. The nurse would interpret this behavior as:

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