A nurse is assisting to collect 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.)
Heel to ear
Popliteal angle
Moro reflex
Scarf sign
Arm recoil
Correct Answer : A,B,D,E
Choice A reason:
Heel to ear is a test that measures the flexibility of the newborn's hip and knee joints. The nurse should gently flex the newborn's hip and knee and bring the foot toward the ear on the same side. The closer the foot is to the ear, the higher the score. This test is part of the neuromuscular assessment for gestational age.
Choice B reason:
Popliteal angle is a test that measures the angle of flexion at the knee joint. The nurse should flex the newborn's hip and knee at 90 degrees and then extend the lower leg until resistance is felt. The smaller the angle, the higher the score. This test is also part of the neuromuscular assessment for gestational age.
Choice C reason:
Moro reflex is a test that evaluates the newborn's startle response. The nurse should hold the newborn in a semi-sitting position and then allow the head to fall back slightly. The newborn should extend and abduct the arms and legs, then flex and adduct them. This test is not part of the neuromuscular assessment for gestational age, but rather a reflex assessment for neurological function. •
Choice D reason:
Scarf sign is a test that measures the flexibility of the newborn's shoulder and elbow joints. The nurse should draw one of the newborn's arms across the chest toward the opposite shoulder. The farther the elbow can be moved across the body, the lower the score. This test is part of the neuromuscular assessment for gestational age.
Choice E reason:
Arm recoil is a test that measures the degree of flexion at the elbow joint. The nurse should extend both of the newborn's arms for 5 seconds and then release them. The arms should return to a flexed position quickly and fully. The faster and more complete the recoil, the higher the score. This test is part of the neuromuscular assessment for gestational age.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Attachment phase is not one of Rubin's phases of role attachment. Rubin's theory of maternal role adaptation describes three stages that the mother goes through during the postpartum period: taking in, taking hold and letting go.
Choice B reason:
Letting go phase is the last stage of Rubin's theory of role attachment. It occurs when the mother accepts her new role and gives up her old roles. She also comes to terms with the reality of the birthing experience and the characteristics of her baby.
Choice C reason:
Taking hold phase is the second stage of Rubin's theory of role attachment. It occurs when the mother becomes interested in caring for the infant and learning about her baby and herself. She may be critical about her care-giving abilities and need positive reinforcement.
Choice D reason:
Taking in phase is the first stage of Rubin's theory of role attachment. It occurs right after the birth of the child, when the mother is passive and focused on her own needs, especially sleeping and eating. She may have limited interactions with her infant and prefer to talk about her experiences during labor, birth, and pregnancy. This matches the description of the new mother in the question, so this is the correct answer.
Correct Answer is B
Explanation
Choice A reason:
Using illicit drugs is not a known cause of congenital hip dysplasia. Illicit drugs may have other harmful effects on the baby, but they do not affect the formation of the hip joint.
Choice B reason:
Unknown. The exact cause of congenital hip dysplasia is not clear. Both genetic and environmental factors seem to play a role in the development of the disorder. Some risk factors include being female, firstborn, breech position, family history, and tight swaddling.
Choice C reason:
Being in nursing school is not a cause of congenital hip dysplasia. This is an irrelevant and incorrect choice.
Choice D reason:
Drinking too much is not a cause of congenital hip dysplasia. Alcohol consumption during pregnancy may increase the risk of fetal alcohol syndrome and other complications, but it does not affect the formation of the hip joint.
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