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.
The Correct Answer is C
To elicit the Moro reflex, the nurse should clap hands after laying the newborn on a flat surface. The Moro reflex, also known as the startle reflex, is an involuntary motor response that infants develop shortly after birth. Loud noises and sudden movements can trigger a baby’s Moro reflex.
Option a is incorrect because turning the newborn's head quickly to one side while they are sleeping may not elicit the Moro reflex.
Option b is incorrect because placing a finger in the newborn's palm may elicit the grasp reflex, not the Moro reflex.
Option d is incorrect because holding the newborn upright with one foot touching the crib surface may not elicit the Moro reflex.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B"]
Explanation
Answer: B
Rationale:
A) Use written signs to assist the client with locating the bathroom: While written signs may be helpful in the earlier stages of Alzheimer's disease, as the disease progresses, clients may lose the ability to read and comprehend written language. Visual cues, such as pictures or color-coded indicators, tend to be more effective in helping clients navigate their environment.
B) Limit the number of choices for the client: Limiting choices reduces confusion and anxiety for clients with Alzheimer's disease. Providing too many options can overwhelm them, making decision-making difficult. Offering simple, clear choices helps to maintain a sense of autonomy while minimizing stress.
C) Provide a stimulating environment for the client: Although some stimulation can be beneficial, excessive stimulation can overwhelm a client with Alzheimer's disease, leading to agitation and confusion. It's important to create a calm, structured environment that promotes safety and reduces anxiety.
D) Use confrontation to manage the client’s behavior: Confrontation should be avoided when managing the behavior of clients with Alzheimer's disease. Confronting or challenging them can increase agitation and lead to further confusion. Instead, caregivers should use distraction, redirection, and a calm approach to manage difficult behaviors effectively.
Correct Answer is B
Explanation
b. Give directions using simple phrases.
The correct answer is b. Give directions using simple phrases.
Explanation:
When assisting with the plan of care for a client with Alzheimer's disease, it is important to consider their cognitive impairments and provide appropriate interventions. Giving directions using simple phrases is recommended because it helps the client beter understand and follow instructions. Complex or lengthy directions can be confusing and overwhelming for individuals with Alzheimer's disease. Using clear and concise language can enhance communication and facilitate the client's ability to engage in activities of daily living.
Explanation for the other options:
a. Encourage the client to talk about current events: While social interaction and engagement are beneficial for clients with Alzheimer's disease, their ability to comprehend and discuss current events may be limited due to cognitive impairments. It is important to adapt communication to the client's cognitive abilities and interests.
c. Orient the client to time and place twice per day: Frequent orientation to time and place can be helpful for clients with Alzheimer's disease, but the specific frequency should be based on the individual's needs and preferences. Some individuals may require more frequent orientation, while others may find it overwhelming. The plan of care should be individualized to address the client's specific needs.
d. Rotate assistive personnel to help the client with ADLs: Consistency and familiarity are important for individuals with Alzheimer's disease. Rotating assistive personnel frequently may disrupt the client's routine and cause increased confusion and agitation. Whenever possible, it is best to maintain a consistent caregiving team to provide familiarity and establish a therapeutic relationship with the client.
In summary, giving directions using simple phrases is an appropriate action when assisting with the plan of care for a client with Alzheimer's disease. This approach promotes effective communication and enhances the client's ability to understand and follow instructions.
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