A nurse is monitoring a client who has bipolar disorder and is exhibiting manifestations of mania.
Which of the following findings should the nurse expect? (Select all that apply.).

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.

Observe the client’s body language during the conversation. This action will help the nurse to assess the client’s nonverbal cues and emotions, which can enhance communication and understanding. The nurse should also determine the client’s understanding several times during the conversation and use lay terms if possible.

Choice A is wrong because avoiding asking the client personal questions can hinder rapport building and prevent the nurse from obtaining important information about the client’s health and needs.

Choice C is wrong because maintaining eye contact with the interpreter when asking questions can show disrespect and disinterest to the client and his family. The nurse should look at the client and his family when asking questions, not at the interpreter.

Choice D is wrong because including medical terminology when discussing the client’s condition can confuse the client and his family and create barriers to communication. The nurse should use simple and clear language that the client and his family can understand.