A nurse is caring for a newborn and assessing newborn reflexes.
To elicit the Moro reflex, what action should the nurse take?
Turn the newborn’s head quickly to one side.
Perform a sharp hand clap near the infant.
Place a finger at the base of the newborn’s toes.
Hold the newborn vertically allowing one foot to touch the table surface.
The Correct Answer is B
Choice A rationale
Turning the newborn’s head quickly to one side does not elicit the Moro reflex. This action can elicit the tonic neck reflex, also known as the “fencing” reflex.
Choice B rationale
Performing a sharp hand clap near the infant can elicit the Moro reflex. This reflex is a response to a sudden loss of support and involves three distinct components: spreading out the arms (abduction), unspreading the arms (adduction), and usually crying.
Choice C rationale
Placing a finger at the base of the newborn’s toes elicits the Babinski reflex, not the Moro reflex.
Choice D rationale
Holding the newborn vertically allowing one foot to touch the table surface does not elicit the Moro reflex. This action can elicit the stepping or walking reflex.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. Drink 48 to 64 ounces of water daily.
Choice A rationale:
Drinking 48 to 64 ounces of water daily is recommended to help maintain hydration and support overall health during pregnancy, especially for those with mild preeclampsia.
Choice B rationale:
While protein intake is important, the recommended amount for pregnant women is generally higher than 40 to 90 grams per day. The exact amount can vary based on individual needs, but typically, pregnant women are advised to consume around 71 grams of protein daily.
Choice C rationale:
Limiting intake of whole grains, raw fruits, and vegetables is not recommended. These foods are rich in essential nutrients and fiber, which are beneficial for both the mother and the baby.
Choice D rationale:
Avoiding salting of foods during cooking can help manage blood pressure, but it is not the primary focus of dietary recommendations for preeclampsia. Reducing overall sodium intake is more important.
Correct Answer is D
Explanation
Choice A rationale
Monitoring weight is important for a newborn who is small for gestational age (SGA), but it is not the priority intervention. Weight can provide information about the newborn’s growth and development, but it does not address immediate physiological needs.
Choice B rationale
Monitoring I&O (Intake and Output) is crucial in assessing the newborn’s hydration status and kidney function. However, it is not the priority intervention for an SGA newborn.
Choice C rationale
Monitoring axillary temperature is important to maintain the newborn’s thermal regulation. However, it is not the priority intervention. Newborns, especially those who are SGA, are at risk for hypothermia due to their high body surface area to volume ratio and lack of subcutaneous fat.
Choice D rationale
Monitoring blood glucose levels is the priority intervention for an SGA newborn. SGA newborns are at risk for hypoglycemia because they have fewer glycogen stores. Hypoglycemia can lead to serious complications such as seizures, hence the need for close monitoring
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