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?

Hold the newborn vertically allowing one foot to touch the table surface.

Perform a sharp hand clap near the infant.

Place a finger at the base of the newborn's toes.

Turn the newborn's head quickly to one side.

Answer and Explanation

The Correct Answer is B

A) Hold the newborn vertically allowing one foot to touch the table surface:

This action describes eliciting the Babinski reflex, not the Moro reflex. The Babinski reflex is elicited by stroking the sole of the foot, causing the toes to fan out and the big toe to dorsiflex while the other toes fan out.

B) Perform a sharp hand clap near the infant:

This action correctly describes eliciting the Moro reflex. The Moro reflex, also known as the startle reflex, is elicited by a sudden movement or loud noise near the infant. The infant responds by extending the arms outward, then bringing them together as if embracing.

C) Place a finger at the base of the newborn's toes:

This action describes eliciting the plantar grasp reflex, not the Moro reflex. The plantar grasp reflex is elicited by stimulating the sole of the foot, causing the toes to curl downward in a grasping motion.

D) Turn the newborn's head quickly to one side:

This action describes eliciting the tonic neck reflex, also known as the fencing reflex, not the Moro reflex. The tonic neck reflex is elicited by turning the infant's head to one side while they are lying supine, causing the limbs on the side the head is turned toward to extend, and the limbs on the opposite side to flex.

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Correct Answer is A

Explanation

A) Initiate early feeding:

Early and frequent breastfeeding or formula feeding helps stimulate bowel movements, which aid in the elimination of bilirubin from the body. Breast milk also contains substances that promote bilirubin excretion, making early feeding an effective preventive measure against neonatal jaundice.

B) Suction excess mucus with a bulb syringe:

While clearing excess mucus can facilitate breathing and feeding, it does not directly prevent jaundice.

C) Prepare for an exchange blood transfusion:

Exchange transfusion is a treatment option for severe jaundice that has not responded to other measures. It is not a preventive measure.

D) Begin phototherapy:

Phototherapy is a treatment for jaundice after it has occurred, not a preventive measure. It involves exposing the newborn's skin to specific wavelengths of light to break down excess bilirubin.

A. Place an identification bracelet. B. Administer eye prophylaxis. C. Administer vitamin K. D. Dry the skin.

Correct Answer is D

Explanation

A. Place an identification bracelet:

While important for identification purposes, placing an identification bracelet is not the priority immediately following birth. Ensuring the newborn's physiological stability takes precedence.

B. Administer eye prophylaxis:

Administering eye prophylaxis is an essential newborn care procedure to prevent neonatal conjunctivitis caused by exposure to maternal gonorrhea or chlamydia. However, it is not the priority immediately after ensuring a patent airway.

C. Administer vitamin K:

Administering vitamin K is important for preventing vitamin K deficiency bleeding (VKDB) in newborns. However, it is typically done after drying the skin and other immediate newborn care tasks.

D. Dry the skin:

This is the correct answer. Drying the newborn's skin is the priority after ensuring a patent airway. Drying helps prevent heat loss and stimulates the newborn's breathing and circulation. It is an essential step in newborn care immediately after birth to promote thermal stability and adaptation to extrauterine life.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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