A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse should take which of the following actions?

A) "You may carry your grandchild to the room":

While it may seem like a polite and accommodating response, allowing the grandmother to carry the newborn to the mother's room poses potential risks. Without proper training and supervision, there is a risk of mishandling or dropping the newborn, especially if the grandmother is unfamiliar with newborn care practices. Therefore, this response does not prioritize the safety and security of the newborn.

B) "Have the mother call and I will take the baby to the room":

This response places the responsibility on the mother to initiate the transfer of the newborn to the room. While it ensures that the mother is aware of and consenting to the movement of the newborn, it may cause delays in reuniting the newborn with the mother. Additionally, if the mother is unable to call or communicate immediately, it could prolong the separation between the newborn and the mother.

C) "If you show me your photo identification, you can take the infant":

Requesting photo identification from the grandmother may seem like a security measure to ensure that only authorized individuals handle the newborn. However, allowing non-staff members to transport newborns without proper supervision or training raises safety concerns. Without proper verification of the grandmother's identity against authorized visitors or family members, this approach may compromise the safety and security of the newborn.

D) "You can push the baby to the room in a wheeled bassinet":

This response prioritizes the safety and security of the newborn by providing a safe and appropriate means of transportation to the mother's room. Using a wheeled bassinet ensures that the newborn is securely positioned and protected during transit. It also aligns with hospital protocols for the safe movement of newborns within the facility, minimizing the risk of accidents or mishaps. Therefore, this response is the most appropriate option to ensure the well-being of the newborn while facilitating the grandmother's desire to take the baby to the mother's room.

A) 48/min:

A respiratory rate of 48 breaths per minute is within the expected reference range for a newborn. The normal range for respiratory rate in newborns is typically between 30 to 60 breaths per minute.

B) 100/min:

A respiratory rate of 100 breaths per minute is above the expected reference range for a newborn. While newborns may exhibit slightly elevated respiratory rates, a rate of 100 breaths per minute is higher than usual and may warrant further assessment.

C) 22/min:

A respiratory rate of 22 breaths per minute is below the expected reference range for a newborn. Normal respiratory rates for newborns are typically higher than 22 breaths per minute.

D) 110/min:

A respiratory rate of 110 breaths per minute is significantly above the expected reference range for a newborn. Such a high respiratory rate may indicate respiratory distress or another underlying issue and requires prompt assessment and intervention.