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.
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. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Uteroplacental insufficiency typically results in late decelerations, not a sudden drop in fetal heart rate, which is more commonly caused by umbilical cord compression.
Choice B rationale
Umbilical cord compression can cause variable decelerations, which are characterized by a sudden drop in fetal heart rate. This occurs due to the umbilical cord being compressed, leading to decreased blood flow and oxygen to the fetus.
Choice C rationale
Maternal bradycardia refers to a slow maternal heart rate and does not directly cause changes in the fetal heart rate pattern.
Choice D rationale
Fetal head compression typically causes early decelerations, which are gradual decreases in fetal heart rate that occur with contractions and are usually benign.
Correct Answer is D
Explanation
Choice A rationale
External fetal monitors are non-invasive and do not pose a risk of transmitting HIV from mother to baby. They are considered safe for monitoring fetal well-being in an HIV-positive mother.
Choice B rationale
Administering antiviral medication is essential in reducing the risk of mother-to-child transmission of HIV. It's a standard care practice for managing HIV-positive pregnant women.
Choice C rationale
Preparing for a caesarean section may be recommended to reduce the risk of vertical transmission of HIV during delivery, especially if the viral load is high.
Choice D rationale
Internal fetal scalp electrodes are contraindicated because they can create a portal for HIV transmission from mother to baby through small abrasions or punctures on the fetal scalp.
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