A nurse is assisting in collecting data for a gestational age assessment on a newborn. Which of the following should the nurse check during a neuromuscular assessment? (Select all that apply.)

Scarf sign

Arm recoil

Moro reflex

Heel to ear

Popliteal angle

Answer and Explanation

Correct Answer : A,B,C

Choice A rationale: The Scarf sign assesses the range of motion of the newborn's shoulder and elbow joint. It measures the ability of the newborn's arm to be brought across the chest.
Choice B rationale: Arm recoil measures the degree of resistance and recoil of the newborn's arm when it is extended and then flexed against the chest. This reflex provides information about the newborn's muscle tone and neuromuscular maturity.
Choice C rationale: The Moro reflex, also known as the startle reflex, is elicited by a sudden change in the newborn's position or by a loud noise. It involves an initial extension and abduction of the arms, followed by a flexion and adduction. This reflex helps assess the newborn's neurologic and neuromuscular maturity.
Choice D rationale: "Heel to ear" is not a standard neuromuscular assessment used in the gestational age assessment. It may be an incorrect or unclear term.
Choice E rationale: The popliteal angle is not a neuromuscular assessment used in the gestational age assessment. It measures the angle of flexion in the knee joint and is not directly related to neuromuscular maturity

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Correct Answer is D

Explanation

Choice A rationale: This response dismisses the client's concerns and is not helpful or informative.
Choice B rationale: While some situations may warrant a repeat cesarean section, this response is not appropriate without knowing the client's specific medical history and the reason for the previous cesarean birth.
Choice C rationale: While there are indeed various factors that impact the possibility of VBAC, the nurse can still provide some general information and considerations to the client, especially regarding the type of uterine incision.
Choice D rationale: This option provides appropriate information to the client regarding VBAC. The type of uterine incision from the previous cesarean birth is a crucial factor in determining whether VBAC is safe and feasible. Clients with a low transverse uterine incision generally have a higher likelihood of being candidates for VBAC.

A. "The best way to determine if your baby can hear is to clap your hands loudly and see if she startles." B. "There is no need to worry about that. Most forms of hearing loss are not Inherited." C. "We do routine hearing screenings on newborns. You'll know the results before you leave the hospital." D. "Look at how she looks as you when you speak. That's a good sign."

Correct Answer is C

Explanation

Choice A rationale: This statement is not accurate, as startling in response to a loud noise does not necessarily indicate that the baby can hear normally. Startling can be a normal reflex response and may not accurately assess the baby's hearing ability.
Choice B rationale: While it is true that many forms of hearing loss are not inherited, the client's concern about her family history of deafness is valid. It is essential to address her concerns and provide appropriate information about the hearing screening.
Choice C rationale: Routine hearing screenings are typically performed on newborns to identify any potential hearing problems early on. Early detection and intervention for hearing loss can lead to better outcomes for the baby's language development and overall well-being. By reassuring the client about the hearing screening, the nurse addresses her concerns and provides information about the process.
Choice D rationale: While visual cues and responses are important for the baby's communication and bonding, they do not provide a definitive assessment of the baby's hearing ability. Hearing screening is a more reliable method to detect potential hearing problems in newborns.

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A nurse is assisting in collecting data for a gestational age assessment on a newborn. Which of the following should the nurse check during a neuromuscular assessment? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who wants to know if it is possible to have a vaginal birth after a cesarean birth (VBAC). Which of the following statements by the nurse is appropriate?

Correct Answer is D

Explanation

A nurse is caring for a client who is postpartum. The client states, "I am concerned about my baby's hearing because my mother was born deaf." Which of the following statements should the nurse make?

Correct Answer is C

Explanation

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