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 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.

A. This can be related to cleaning her perineal area. Be more careful. B. The baby may have a problem. Let's schedule an appointment. C. If this continues, call us back. For now, just watch her. D. This can be from the sudden withdrawal of your hormones. It is not a cause for alarm.

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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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

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?

Correct Answer is A

Explanation

A new mother of a newborn girl calls the clinic in a panic, concerned about the blood-tinged soiled diaper. What is the best response from the nurse?

Correct Answer is D

Explanation

A woman had a vaginal delivery two days ago and is preparing for discharge. To help prevent postpartum complications, the nurse plans to teach the woman to report any:

A new mother of a newborn girl calls the clinic in a panic, concerned about the blood-tinged soiled diaper. What is the best response from the nurse?

The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client?

The nurse is caring for a new mother and newborn in a rooming-in unit and watches the mother put the infant in the bed, lying on her side, propped up with a pillow. The nurse should point out that this position can increase the risk of which situation?

The 1-day postpartum patient shows a temperature elevation, cough, and slight shortness of breath on exertion. Based on these symptoms, the nurse should:

A nurse is teaching a new mother about signs of effective breastfeeding of her newborn. Which of the following information should the nurse include in the teaching?

The nurse is visiting a new mother who has been home with a new infant for 4 days. Which observation indicates that the mother's home environment was inadequately assessed prior to being discharged from the hospital?

A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client's perineal pad. Which of the following actions should the nurse take first?