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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Asymmetrical chest movement is a sign of respiratory distress in the newborn, as it indicates unequal lung expansion or airway obstruction. A respiratory rate of 50 breaths/minute (choice B) is normal for a newborn, as is acrocyanosis (choice C), which is a bluish discoloration of the hands and feet due to immature peripheral circulation. Short periods of apnea (less than 15 seconds) (choice D) are also common and benign in newborns unless they are associated with bradycardia or cyanosis.
Choice B is not correct because a respiratory rate of 50 breaths/minute is within the normal range for a newborn.
Choice C is not correct because acrocyanosis is a normal finding in newborns and does not indicate respiratory distress.
Choice D is not correct because short periods of apnea (less than 15 seconds) are normal in newborns and do not indicate respiratory distress.
Correct Answer is D
Explanation
This can be from the sudden withdrawal of your hormones. It is not a cause for alarm. This is because newborn female babies may have a little bloody vaginal discharge in their diapers due to the withdrawal of maternal hormones after delivery. This usually stops as the hormones return to normal levels. The nurse should reassure the mother that this is a normal and harmless phenomenon and does not require any treatment.
Choice A is wrong because the blood is not related to cleaning her perineal area. The nurse should not blame the mother for being careless.
Choice B is wrong because the baby does not need an appointment for this condition. The nurse should not alarm the mother unnecessarily.
Choice C is wrong because the mother does not need to watch her baby for this condition. The nurse should not leave the mother in doubt or anxiety.
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