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 their abdomen and observe the movement of their extremities.
Stroke the newborn’s cheek toward their mouth.
Stroke upward on the lateral aspect of the newborn’s foot.
Place the newborn on a flat surface and clap hands loudly.
The Correct Answer is D
Place the newborn on a flat surface and clap hands loudly.
This action will elicit the Moro reflex, also known as the startle reflex, which is a normal, involuntary reaction that newborns and infants have when they’re startled. In response to the sound, the baby will throw back his or her head, extend out his or her arms and legs, cry, then pull the arms and legs back in.
Choice A is wrong because placing the newborn on their abdomen and observing the movement of their extremities will not trigger the Moro reflex.
This position may elicit other reflexes such as the crawling reflex or the tonic neck reflex.
Choice B is wrong because stroking the newborn’s cheek toward their mouth will not trigger the Moro reflex. This action will elicit the rooting reflex, which helps the baby find the breast or bottle to start feeding.
Choice C is wrong because stroking upward on the lateral aspect of the newborn’s foot will not trigger the Moro reflex. This action will elicit the Babinski reflex, which causes the big toe to extend upward and the other toes to fan out.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
“I will turn all pot handles toward the back of the stove.” This indicates that the guardian understands how to prevent the toddler from pulling a pot off the stove and getting burned.
Choice B is wrong because a child’s car seat should be rear-facing until the child is at least 2 years old or reaches the maximum height and weight for the seat.
Choice C is wrong because the temperature of the water heater should be set to no higher than 120 degrees to prevent scalding injuries.
Choice D is wrong because drop-side cribs are banned in the United States due to the risk of entrapment and suffocation.
Correct Answer is D
Explanation
The nurse should offer the client a milkshake because it is a high-calorie, high- protein, and easy-to-consume food that can meet the nutritional needs of a client who is in the manic phase of bipolar disorder. Clients who are manic often have increased activity, decreased appetite, and poor attention span, which can lead to weight loss and malnutrition.
Choice A is wrong because Creamed corn is wrong because it is a low-protein, high-carbohydrate food that can increase blood glucose levels and cause mood swings.
Choice B is wrong because Mashed potatoes is wrong because it is a low-protein, high-starch food that can also affect blood glucose levels and mood stability.
Choice C is wrong because Spaghetti with meat sauce is wrong because it is a complex food that requires utensils and attention to eat, which can be difficult for a client who is manic and distractible.
Normal ranges for potassium are 3.5 to 5.0 mEq/L.
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