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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
c. Instruct the client to use abdominal breathing.
When a client is experiencing a panic atack, the nurse's first priority is to help the client manage their symptoms and provide immediate relief. Instructing the client to use abdominal breathing is the most appropriate initial intervention.
Explanation for the other options:
a. Discuss the client's feelings prior to the panic atack. While discussing the client's feelings can be beneficial in addressing the underlying causes of anxiety, it may not be the most effective immediate intervention during a panic atack. The client's focus during a panic atack is typically on managing the physical symptoms and regaining control.
b. Encourage the use of positive self-talk strategies. Positive self-talk can be helpful in managing anxiety in general, but during a panic atack, the individual may have difficulty engaging in positive self-talk due to the intensity of symptoms. Addressing the immediate physical symptoms is a priority before exploring coping strategies.
d. Administer an anti-anxiety medication. Medication administration may be necessary in some cases, but it is not the first-line intervention for managing a panic atack. Non-pharmacological interventions, such as breathing techniques, should be implemented first. If the panic atack persists or worsens despite these interventions, medication may be considered.
In summary, during a panic atack, the immediate focus should be on helping the client manage their symptoms. Instructing the client to use abdominal breathing can help promote relaxation and reduce the intensity of the panic atack.
Correct Answer is A
Explanation
The nurse should include the instruction to "verify the identity of anyone who wants to remove your baby from the room" in the teaching about security procedures. It is important for parents to be vigilant and ensure that only authorized personnel have access to their baby.
Option b is incorrect because it may not be safe for the parent to leave their baby unattended in their room while they walk in the hallway.
Option c is incorrect because newborns typically have two identification bands, one on their arm and one on their leg.
Option d is incorrect because parents should not leave the unit with their baby without proper authorization and discharge procedures.
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