A nurse is checking a newborn's Moro reflex. Which of the following actions should the nurse take to elicit this reflex?
Place the newborn on a flat surface and clap hands loudly.
Stroke the newborn's cheek toward their mouth.
Stroke upward on the lateral aspect of the newborn's foot.
Place the newborn on their abdomen and observe the movement of their extremities.
The Correct Answer is A
A. Place the newborn on a flat surface and clap hands loudly:
A sudden loud noise or movement causes the newborn to extend and abduct arms, then adduct them – the Moro (startle) reflex.
B. Stroke the newborn's cheek toward their mouth:
This tests the rooting reflex, not the Moro reflex.
C. Stroke upward on the lateral aspect of the newborn's foot:
This elicits the Babinski reflex, not Moro.
D. Place the newborn on their abdomen and observe the movement of their extremities:
This would assess gross motor tone or posture, not the Moro reflex.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Encourage the client to rest in bed during the day.
Promotes isolation and worsens depression. Activity should be encouraged.
B. Request a prescription for antidiarrheal medication.
Constipation, not diarrhea, is a more common vegetative symptom.
C. Provide low-calorie snacks throughout the day.
High-calorie, nutrient-dense foods are better for clients with poor appetite.
D. Offer the client high-protein fluids frequently.
Vegetative symptoms include poor appetite-offering high-protein fluids helps maintain nutrition and hydration.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Condition – Ectopic pregnancy; Finding – Right lower quadrant abdominal tenderness
Ectopic pregnancy – Right lower quadrant abdominal tenderness
A missed period, positive hCG, and right lower quadrant pain are classic signs of ectopic pregnancy, a life-threatening condition.
Other combinations are ruled out as follows:
- Placenta previa – Incorrect: Usually presents in later pregnancy with painless bright red bleeding.
- Pyelonephritis – Temperature – Incorrect: The client has normal temperature and no urinary symptoms.
- Acute asthma attack – Hyperactive bowel sounds – Incorrect: No respiratory distress or wheezing; hyperactive bowel sounds are GI-related.
- Abruptio placentae – Respiratory rate – Incorrect: RR is normal and this condition is also more likely in later pregnancy
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