A nurse in the newborn nursery is collecting data about a newborn's Moro reflex. Which of the following actions should the nurse take to elicit this reflex?

Turn the newborn's head quickly to one side while they are sleeping.

Place a finger in the newborn's palm.

Clap hands after laying the newborn on a flat surface.

Hold the newborn upright with one foot touching the crib surface

None

Answer and Explanation

The Correct Answer is C

A. Turn the newborn's head quickly to one side while they are sleeping: This action does not elicit the Moro reflex. The Moro reflex is a response to a sudden loss of support, not a head-turning motion.

B. Place a finger in the newborn's palm: This action would elicit the palmar grasp reflex, not the Moro reflex.

C. Clap hands after laying the newborn on a flat surface: The Moro reflex is triggered by a sudden, loud noise or movement, such as clapping hands. This response causes the newborn to extend and then quickly flex the arms, a characteristic sign of the reflex.

D. Hold the newborn upright with one foot touching the crib surface: This action is not related to the Moro reflex. The stepping reflex is elicited by holding the newborn upright with their feet touching a surface, not the Moro reflex.

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Correct Answer is A

Explanation

A. "I will take a stool softener to prevent constipation." This is correct. Postoperative clients, especially those who are on opioid medications for pain management, are at risk for constipation. Taking a stool softener is a good strategy to prevent this complication after surgery.

B. "I will ask to work the night shift, so I will not be driving in bright sunlight." This is incorrect. Following laser surgery for open-angle glaucoma, clients are typically advised to avoid bright lights and glare, but there is no need to change work schedules. The focus should be on wearing protective sunglasses to shield the eyes from sunlight and glare, not on avoiding daytime work hours.

C. "I will need to use my eye drops for 1 year." This is incorrect. While eye drops may be prescribed to manage intraocular pressure, the duration of use will depend on the specific medication and the client's condition. It is not typically necessary to use them for an entire year after laser surgery, and the client should follow the provider's instructions for tapering or stopping the medication as indicated.

D. "I will need to follow a low-protein diet." This is incorrect. There is no specific dietary restriction for a low-protein diet following laser surgery for open-angle glaucoma. The client should follow a balanced diet as recommended by the healthcare provider.

A. Falls asleep 5 min after starting a feeding B. Has 3 wet diapers each day C. Has a bowel movement every other day D. Makes audible swallowing sounds E. Makes audible swallowing sounds

Correct Answer is D

Explanation

A. Falling asleep 5 minutes after starting a feeding may indicate that the newborn is not effectively breastfeeding and may not be getting enough milk.
B. Having three wet diapers each day is an important indicator of hydration but does not directly correlate with effective breastfeeding.
C. Having a bowel movement every other day may vary depending on the newborn's age and feeding patterns and is not necessarily an indicator of effective breastfeeding.
D. Audible swallowing sounds during breastfeeding indicate that the newborn is effectively latching onto the breast and extracting milk. This suggests that the newborn is receiving an adequate amount of milk during feeding sessions.

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A nurse in the newborn nursery is collecting data about a newborn's Moro reflex. Which of the following actions should the nurse take to elicit this reflex?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is D

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