A nurse is caring for a newborn. Which of the following actions by the newborn indicates a readiness to feed?

Lies quietly with their eyes open

Spits up clear mucus

Turns the head towards sounds

Attempts to place their hand in their mouth

Answer and Explanation

The Correct Answer is D

A. Lies quietly with their eyes open: While a newborn being calm and alert may indicate they are awake, it does not necessarily indicate hunger or readiness to feed. The baby may be observing the environment or feeling content.

B. Spits up clear mucus: This is a sign that the baby may need to clear their airways or is experiencing mild reflux, but it does not indicate readiness to feed. Spitting up is more related to digestion and respiratory function.

C. Turns the head towards sounds: This is a sign of the newborn's ability to respond to stimuli, but it is not a specific indicator of hunger. Newborns often turn their heads toward sounds or voices as part of their natural reflexes.

D. Attempts to place their hand in their mouth: This is a classic sign of hunger in newborns. They often exhibit this behavior when they are ready to feed as a natural instinct to self-soothe or stimulate feeding reflexes. Other early cues include licking motions, lip smacking, and rooting. Feeding should ideally occur during these early cues rather than waiting until the baby cries, which is a late sign of hunger and can make latching more difficult.

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Correct Answer is C

Explanation

A. Place the newborn in a radiant warmer: While a radiant warmer is useful for addressing hypothermia, the symptoms described, diaphoresis, jitteriness, and lethargy, are more indicative of hypoglycemia, not cold stress. The first step is to check the blood glucose.

B. Monitor the newborn's blood pressure: Although blood pressure may be monitored in cases of neonatal distress, the symptoms described are more likely associated with hypoglycemia, so the priority action should be to check glucose levels.

C. Obtain blood glucose by heel stick: The symptoms of diaphoresis, jitteriness, and lethargy are common signs of hypoglycemia in newborns. A heel stick to obtain blood glucose is the most appropriate action to confirm this and initiate treatment if needed.

D. Initiate phototherapy: Phototherapy is used to treat jaundice (hyperbilirubinemia), but the signs observed do not point to jaundice, making phototherapy an inappropriate first action in this scenario.

A. Perform a sharp hand clap near the infant. B. Hold the newborn vertically allowing one foot to touch the table surface. C. Place a finger at the base of the newborn's toes. D. Turn the newborn's head quickly to one side.

Correct Answer is A

Explanation

A. Perform a sharp hand clap near the infant: The Moro reflex, also known as the startle reflex, is elicited by producing a sudden loud noise or a slight jarring motion. A sharp hand clap near the infant mimics a startling event, causing the newborn to respond by abducting and extending the arms, opening the hands, and then adducting the arms in an embracing motion. This reflex is a sign of normal neurologic development in neonates.

B. Hold the newborn vertically allowing one foot to touch the table surface: This action is used to elicit the stepping reflex, where the newborn appears to take steps or dance when the soles of the feet touch a flat surface. It does not relate to the Moro reflex.

C. Place a finger at the base of the newborn's toes: This technique elicits the plantar grasp reflex, where the toes curl around the examiner’s finger. It evaluates neurologic function, but is unrelated to the Moro reflex.

D. Turn the newborn's head quickly to one side: This maneuver is used to assess the tonic neck reflex (also known as the "fencing" reflex), in which the arm on the side the head is turned extends, while the opposite arm flexes. It is not used to elicit the Moro reflex

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A nurse is caring for a newborn. Which of the following actions by the newborn indicates a readiness to feed?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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

Correct Answer is A

Explanation

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