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

Assessing the client's blood pressure can help determine if there is a significant loss of blood and consequent hypotension. However, it is not the immediate first action to manage heavy bleeding postpartum.

Choice B rationale

Assessing the bladder for distention is crucial as a full bladder can interfere with uterine contraction, potentially leading to increased bleeding. But, it isn't the first priority compared to addressing the immediate bleeding.

Choice C rationale

Massaging the client's fundus is the priority action in this case. It helps to contract the uterus, thereby reducing bleeding. Uterine atony is the most common cause of postpartum hemorrhage, and fundal massage is the first intervention to manage it.

Choice D rationale

Preparing to administer a prescription may be necessary, especially if uterotonics are required. However, this is a subsequent step after attempting to control the bleeding through fundal massage.

A. Administer prescribed antipyretics for maternal fever. B. Prepare the client for emergency cesarean section. C. Administer glucocorticoids intramuscularly. D. Recheck the client's temperature in 4 hr.

Correct Answer is A

Explanation

Choice A rationale

Administering antipyretics for maternal fever is essential as elevated maternal temperatures can increase the risk of fetal tachycardia and potentially lead to fetal distress. Reducing fever promptly is a priority to stabilize both maternal and fetal conditions.

Choice B rationale

Preparing for an emergency cesarean section is not the immediate step for maternal fever; instead, managing the fever and assessing the need for further interventions based on the overall clinical picture should be prioritized.

Choice C rationale

Administering glucocorticoids is indicated for promoting fetal lung maturity in preterm labor, not specifically for maternal fever management. Fever management requires antipyretics and hydration.

Choice D rationale

Waiting 4 hours to recheck temperature delays prompt management, increasing risks for both the mother and fetus. Immediate action to reduce fever is crucial to prevent potential complications.

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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 client who is 6 hours postpartum following a vaginal birth.The client has saturated a perineal pad within 15 minutes.Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is providing care to a woman who is at 36 weeks of gestation and in preterm labor with ruptured membranes.The nurse determines that the client's oral temperature is 39.0 C (102.2 F). Besides notifying the provider, which of the following is an appropriate nursing action?

Correct Answer is A

Explanation

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