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

Turn the newborn's head quickly to one side.

Perform a sharp hand clap near the infant.

Stroke the outer edge of the sole of the foot from near the heel up toward the toes.

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

Answer and Explanation

The Correct Answer is B

Choice A rationale

Turning the newborn's head quickly to one side elicits the tonic neck reflex, not the Moro reflex. The tonic neck reflex involves the newborn's arm extending on the side where the head is turned and the opposite arm bending at the elbow, resembling a fencing position.

Choice B rationale

Performing a sharp hand clap near the infant elicits the Moro (startle) reflex, which is characterized by the infant throwing their arms outward, opening their hands, and then bringing the arms back in. This is a response to sudden stimuli and is a normal reflex in newborns.

Choice C rationale

Stroking the outer edge of the sole of the foot from near the heel up toward the toes elicits the Babinski reflex, not the Moro reflex. The Babinski reflex is characterized by the big toe moving upward or toward the top surface of the foot and the other toes fanning out.

Choice D rationale

Placing a finger at the base of the newborn's toes elicits the plantar grasp reflex, not the Moro reflex. The plantar grasp reflex involves the toes curling around the finger or object placed at the base of the toes. .

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Correct Answer is C

Explanation

Choice A rationale

Accelerations are increases in the fetal heart rate (FHR) above the baseline, typically in response to fetal movement or uterine contractions. They indicate a healthy, well-oxygenated fetus and are not consistent with the described pattern of decelerations.

Choice B rationale

Late decelerations are characterized by a gradual decrease in FHR that begins after the contraction has started, with the lowest point of the deceleration (nadir) occurring after the peak of the contraction. They are associated with uteroplacental insufficiency and fetal hypoxia, which is not described in the scenario.

Choice C rationale

Early decelerations are a gradual decrease in FHR that mirrors the contraction, starting with the contraction and returning to baseline as the contraction ends. The nadir of the deceleration occurs at the peak of the contraction, which fits the pattern described.

Choice D rationale

Variable decelerations are abrupt decreases in FHR that can occur at any time during the contraction cycle, usually due to umbilical cord compression. They are not uniform in relation to contractions and can vary in duration, depth, and timing, unlike the described pattern.

A. The baby will sneeze. B. The baby will move their legs in a bicycle motion. C. The baby will put their hand to their mouth. D. The baby will extend both arms to the side of their body.

Correct Answer is C

Explanation

Choice A rationale

Sneezing is a reflex action to clear the nasal passages and is not a feeding cue. It does not indicate hunger but is more likely related to environmental irritants or the baby adjusting to breathing air.

Choice B rationale

Moving legs in a bicycle motion is a common newborn reflex that is associated with general activity or discomfort, rather than a specific signal of hunger. This movement is typically seen during periods of wakefulness or while the baby is trying to soothe themselves.

Choice C rationale

Putting their hand to their mouth is a well-recognized hunger cue in newborns. This behavior often precedes crying and indicates that the baby is ready to feed. It's a self-soothing mechanism that also signals hunger.

Choice D rationale

Extending both arms to the side of their body is more related to the Moro reflex, which is a startle reflex in response to a sudden movement or noise. It is not associated with feeding cues or hunger.

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

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Correct Answer is C

Explanation

A nurse is assisting a teenage client with breastfeeding.The client asks, "How will I know when to feed my baby?" The nurse educates the client on infant feeding cues.Which of the following is a newborn feeding cue?

Correct Answer is C

Explanation

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