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 D
Explanation
Sternal or chest retractions. This is because sternal or chest retractions are a sign of respiratory distress in newborns, which means they are having difficulty breathing. Chest retractions occur when the baby's chest pulls in with each breath, indicating that they are using extra muscles to breathe. This can be caused by various conditions that affect the lungs, such as respiratory distress syndrome (RDS), transient tachypnea of the newborn (TTN), meconium aspiration syndrome (MAS), pneumonia, or congenital heart defects.
Choice A is not correct because mucus draining from the nose is not a symptom of respiratory distress in newborns. It is normal for newborns to have some mucus in their nose and mouth after birth, which can be cleared by suctioning or wiping.
Mucus drainage does not interfere with breathing unless it is excessive or thick.
Choice B is not correct because cyanosis of the hands and feet is not a symptom of respiratory distress in newborns. It is normal for newborns to have bluish discoloration of their hands and feet, called acrocyanosis, for the first few days after birth. This is due to immature circulation and does not indicate a lack of oxygen. Cyanosis of the central parts of the body, such as the face, lips, and tongue, is more concerning and should be reported.
Choice C is not correct because irregular heart rate is not a symptom of respiratory distress in newborns. It is normal for newborns to have some variations in their heart rate, especially during sleep cycles. The normal heart rate range for newborns is 100 to 160 beats per minute. A heart rate that is too fast (tachycardia) or too slow (bradycardia) may indicate a problem with the heart or other organs³.
Correct Answer is A
Explanation
This action helps to prevent cold stress. This is because cold stress is a condition where the newborn's core temperature drops below 36.5°C and they use energy and oxygen to generate warmth. This can lead to hypoglycemia, metabolic acidosis, hypoxia, and an increased risk of infection.
Placing the newborn under a radiant warmer provides thermal stability and prevents heat loss by radiation.
Choice B is wrong because thermogenesis is the process of heat production, not a complication.
Choice C is wrong because shivering is a mechanism of heat production in adults, not in newborns.
Choice D is wrong because brown fat production is a normal feature of newborns that helps them generate heat by lipolysis.
Here is an image of a newborn under a radiant warmer.
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