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 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.

A. Brisk patellar deep tendon reflexes. B. Moderate amount of lochia on the perineal pad over 2 hours. C. Fundus at level of umbilicus. D. Approximated edges of episiotomy.

Correct Answer is A

Explanation

Choice A rationale

Brisk patellar deep tendon reflexes can indicate central nervous system irritability, which might suggest conditions like preeclampsia or eclampsia if accompanied by other symptoms. It's critical to assess and monitor for further complications.

Choice B rationale

A moderate amount of lochia on the perineal pad over 2 hours is normal postpartum bleeding and does not typically indicate an immediate concern if within expected ranges.

Choice C rationale

A fundus at the level of the umbilicus is an expected finding 4 hours postpartum and indicates normal uterine involution. It is not a priority concern at this stage.

Choice D rationale

Approximated edges of an episiotomy indicate that the incision is healing properly without signs of infection or dehiscence. This is a normal and expected finding in the postpartum period.

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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 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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Correct Answer is A

Explanation

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