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 {"dropdown-group-1":"B"}
Explanation
The Apgar score is a scoring system used by doctors and nurses to assess newborns one minute and five minutes after they are born. The score is based on five criteria: activity, pulse, grimace, appearance, and respiration, with each criterion receiving a score of 0 to 2 points.
If we apply this scoring system to the information provided, the newborn's 1- minute Apgar score would be:
Activity: 1 point (limbs flexed)
Pulse: 1 point (heart rate less than 100 beats per minute) Grimace: 1 point (facial movement/grimace with stimulation) Appearance: 1 point (body pink but extremities blue) Respiration: 1 point (irregular, weak crying)
The total score is 5 points, which is considered moderately abnormal.
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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