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 {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Given the provided information, here is the completion of the sentence using the options:

The newborn most likely has Brachial plexus injury as evidenced by Asymmetrical Moro reflex.

This conclusion is drawn from the observation that the newborn does not move the left arm during the Moro reflex, which is indicative of a possible brachial plexus injury. This type of injury can occur during childbirth, especially in cases involving shoulder dystocia and vacuum-assisted delivery.

The reason for diagnosing the newborn with a brachial plexus injury is based on the observation that the newborn does not move the left arm during the Moro reflex. The Moro reflex, also known as the startle reflex, is a normal response in newborns where they spread out their arms and then bring them back towards the body when they feel a sudden loss of support. In this case, the newborn is only moving one arm, which suggests that there might be an injury to the nerves that control movement in the affected arm.

Brachial plexus injuries often occur during difficult births, such as those involving shoulder dystocia and vacuum-assisted deliveries. These types of injuries can lead to weakness or paralysis of the affected arm. Given the details of the newborn's birth and the absence of movement in the left arm during the Moro reflex, a brachial plexus injury is the most likely condition.

A. Uterine atony. B. Thrombophlebitis. C. Postpartum preeclampsia. D. Retained placental fragments.

Correct Answer is A

Explanation

Choice A rationale

Uterine atony is a common complication following polyhydramnios because the excessive amniotic fluid can lead to uterine overdistension, which in turn can cause poor uterine muscle tone and increased risk of postpartum hemorrhage.

Choice B rationale

Thrombophlebitis is an inflammation of a vein with clot formation, but it is not directly associated with polyhydramnios.

Choice C rationale

Postpartum preeclampsia is high blood pressure and signs of organ damage after delivery, but there is no direct link between polyhydramnios and this condition.

Choice D rationale

Retained placental fragments can lead to postpartum hemorrhage but are not specifically associated with polyhydramnios.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn who is 4 hours old in the newborn unit. Exhibits Complete the following sentence by using the list of options: The newborn most likely has dropdown as evidenced by dropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

A nurse is caring for a client whose pregnancy was complicated by polyhydramnios and is now 5 hours postpartum following a vaginal birth.The nurse should recognize that this client is at risk for which of the following postpartum complications?

Correct Answer is A

Explanation

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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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A nurse in a provider's office is caring for a 32-year-old female client who is pregnant. Exhibits Which of the following assessment findings should the nurse report to the provider? (Select all that apply.)