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?
Place a finger at the base of the newborn’s toes.
Turn the newborn’s head quickly to one side.
Hold the newborn vertically allowing one foot to touch the table surface.
Perform a sharp hand clap near the infant.
The Correct Answer is D
Choice A reason:
Placing a finger at the base of the newborn’s toes is used to elicit the Babinski reflex, not the Moro reflex. The Babinski reflex is observed when the toes fan out and the big toe moves upward in response to stroking the sole of the foot1. This reflex is a normal finding in infants up to 2 years old and indicates normal neurological development.
Choice B reason:
Turning the newborn’s head quickly to one side is used to elicit the tonic neck reflex, also known as the “fencing” reflex. When the head is turned to one side, the arm on that side extends while the opposite arm bends at the elbow, resembling a fencing position2. This reflex is typically present from birth to about 6 months of age.
Choice C reason:
Holding the newborn vertically and allowing one foot to touch the table surface is used to elicit the stepping reflex. When the baby’s foot touches a surface, they will make stepping movements as if trying to walk3. This reflex is usually present from birth until about 2 months of age.
Choice D reason:
Performing a sharp hand clap near the infant is a method to elicit the Moro reflex, also known as the startle reflex. The Moro reflex is triggered by a sudden loud noise or a sensation of falling. The infant will respond by extending and abducting the arms, opening the hands, and then bringing the arms back to the body. This reflex is present at birth and typically disappears by 4 to 6 months of age.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Reddened with a small amount of bloody drainage is a common finding immediately after circumcision. However, this is not the expected appearance after the initial healing phase. The presence of bloody drainage should decrease over time, and the site should begin to show signs of healing.
Choice B Reason:
Pink without drainage is not typical immediately after circumcision. The surgical site will usually be red and may have some drainage as part of the normal healing process. A completely pink and dry site would be expected only after full healing has occurred.
Choice C Reason:
Reddened with a scant amount of yellow exudate is the expected appearance during the healing process. The yellow exudate is part of the normal healing response and should not be mistaken for infection. This exudate typically appears within the first few days after circumcision and indicates that the healing process is progressing normally.
Choice D Reason:
Reddened, with copious blood is not normal and indicates a potential complication. Copious bleeding from the circumcision site requires immediate medical attention as it may suggest an issue with clotting or a problem with the surgical site.
Correct Answer is ["C","D"]
Explanation
Choice A reason:
“Small for gestational age” (SGA) refers to babies who are smaller than the typical weight for their gestational age, usually below the 10th percentile. An 8-pound 15-ounce baby born at 35 weeks is not considered SGA because this weight is above the average for that gestational age
Choice B reason:
“Term” refers to babies born between 37 and 42 weeks of gestation. Since the baby in question was born at 35 weeks, they are not considered term.
Choice C reason:
“Preterm” refers to babies born before 37 weeks of gestation. A baby born at 35 weeks falls into this category and is specifically classified as a “late preterm” infant3. Late preterm infants are those born between 34 and 36 weeks of gestation. These babies may require additional medical support compared to full-term infants but generally have better outcomes than those born earlier.
Choice D reason:
“Average for gestational age” (AGA) refers to babies whose weight is within the normal range for their gestational age, typically between the 10th and 90th percentiles. An 8-pound 15-ounce baby born at 35 weeks is considered AGA because this weight is within the expected range for that gestational age.
Choice E reason:
“Post term” refers to babies born after 42 weeks of gestation. Since the baby in question was born at 35 weeks, they are not considered post term.
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