A nurse is collecting data about reflexes from a newborn. Which of the following actions should the nurse take to elicit the newborn's Moro reflex?
Perform a sharp hand clap near the infant.
Turn the newborn's head quickly to one side.
Place a finger at the base of the newborn's toes.
Hold the newborn vertically, allowing one foot to touch the crib surface.
The Correct Answer is A
Choice A rationale:
The Moro reflex, also known as the startle reflex, is a normal reflex observed in newborns. To elicit this reflex, the nurse should perform a sharp hand clap or make a loud noise near the infant. This reflex is characterized by the baby's arms and legs extending outward, followed by a quick flexion, resembling a startle response. It is an important reflex to assess the newborn's neurological and motor development.
Choice B rationale:
Turning the newborn's head quickly to one side does not elicit the Moro reflex. This action may stimulate other reflexes, such as the tonic neck reflex, but it is not the appropriate method to assess the Moro reflex.
Choice C rationale:
Placing a finger at the base of the newborn's toes does not elicit the Moro reflex. This action is more related to testing the Babinski reflex, which involves the fanning and curling of the toes when the sole of the foot is stimulated.
Choice D rationale:
Holding the newborn vertically and allowing one foot to touch the crib surface does not elicit the Moro reflex. This action might elicit the stepping reflex, where the baby shows stepping movements as if walking when held in an upright position with their feet touching a surface.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
Choice A rationale:
Washing the penis with warm water and mild soap each day is not an appropriate statement regarding circumcision care with a Plastibell device. Keeping the area clean is essential, but soap may irritate the wound, and frequent washing can disrupt the healing process.
Choice B rationale:
Ensuring a loose diaper in the front is not directly related to circumcision care with a Plastibell device. It may be relevant for comfort, but it does not address specific care for the circumcision site.
Choice C rationale:
This is a correct statement indicating understanding of circumcision care with the Plastibell device. The plastic ring is expected to fall off on its own within a week, and this is a normal part of the healing process.
Choice D rationale:
Applying petroleum jelly to the penis during diaper changes is not recommended for circumcision care with a Plastibell device. The petroleum jelly can interfere with wound healing and should be avoided.
Choice E rationale:
This is also a correct statement indicating understanding of circumcision care. If bleeding occurs after the Plastibell has fallen off, it could be a sign of a complication, and the doctor should be notified promptly.
Correct Answer is B
Explanation
Rooting. Choice A rationale:
The Moro reflex is a startle reflex characterized by the infant's sudden extension and abduction of the arms in response to a loud noise or sudden movement. It is not involved in the initiation of sucking and is unrelated to breastfeeding.
Choice B rationale:
The rooting reflex is a crucial reflex that helps initiate sucking in newborns. When the infant's cheek is stroked or touched, they will turn their head toward the stimulus and open their mouth, preparing for feeding. This reflex helps the infant find the mother's nipple and begin breastfeeding effectively.
Choice C rationale:
The stepping reflex is a primitive reflex observed in newborns when held upright with their feet touching a solid surface. The baby will make stepping movements, mimicking walking. However, this reflex is not related to the initiation of sucking and breastfeeding.
Choice D rationale:
The Babinski reflex is a reflex in which the big toe extends upward and the other toes fan out when the sole of the foot is stimulated. This reflex is present in newborns and disappears as the child grows older. It is not involved in the initiation of sucking.
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