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","C","D"]

Explanation

A) "I'll make sure his diaper is loose in the front":

This statement indicates understanding because ensuring a loose diaper helps prevent irritation and discomfort to the healing circumcision site. Tight diapers can rub against the area and cause irritation or disrupt the healing process.

B) "I'll apply petroleum jelly to his penis with diaper changes":

While applying petroleum jelly to the penis with diaper changes is a common practice for circumcision care, it is not recommended for the Plastibell technique. Using petroleum jelly can interfere with the plastic ring and may prevent it from falling off naturally.

C) "I'll expect the plastic ring to fall off by itself within a week":

This statement indicates understanding because with the Plastibell technique, the plastic ring is left in place until it falls off on its own, typically within a week after the procedure. It is essential for the client to be aware of this expected outcome.

D) "I'll call the doctor if I see any bleeding":

This statement indicates understanding because it shows recognition of the potential complication of bleeding post-circumcision. While some minor bleeding may occur initially, excessive bleeding should be reported to the doctor promptly for further evaluation and management.

E) "I'll wash his penis with warm water and mild soap each day":

While keeping the area clean with warm water and mild soap is generally recommended for circumcision care, with the Plastibell technique, it is typically advised to avoid washing the area directly until the plastic ring falls off. Direct washing may interfere with the healing process or disrupt the plastic ring. Therefore, this statement does not indicate understanding of circumcision care with the Plastibell technique.

A. Initiate early feeding. B. Suction excess mucus with a bulb syringe. C. Prepare for an exchange blood transfusion. D. Begin phototherapy.

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.

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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

A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

Correct Answer is A

Explanation

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