When assessing a newborn, which is the best method for the nurse to use to elicit the Moro reflex?
Making a loud sound within close range of the newborn.
Firmly stroking the soles of the newborn’s feet with a thumb nail.
Using the newborn’s hands to raise the baby from a supine position without supporting the head.
Holding the newborn in an upright position so that the infant’s feet touch a cool, flat surface.
The Correct Answer is A
The correct answer is choice A. Making a loud sound within close range of the newborn will elicit the Moro reflex, which is an involuntary protective motor response against abrupt disruption of body balance or extremely sudden stimulation. The Moro reflex involves three distinct components: spreading out the arms (abduction), pulling the arms in (adduction), and crying (usually).
Choice B is wrong because firmly stroking the soles of the newborn’s feet with a thumb nail will elicit the Babinski reflex, which is a normal response in infants that involves fanning out and curling of the toes.
Choice C is wrong because using the newborn’s hands to raise the baby from a supine position without supporting the head will elicit the traction response, which is a normal response in infants that involves flexion of the elbows and shoulders.
Choice D is wrong because holding the newborn in an upright position so that the infant’s feet touch a cool, flat surface will elicit the stepping reflex, which is a normal response in infants that involves alternating steps with each foot.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Stretching your legs and pointing your toes toward your knee will bring relief from the leg cramps.This is because stretching can help relax the muscle and ease the spasm.
Choice A is wrong because elevating your legs may not help with leg cramps, and may actually worsen them by reducing blood flow to the muscles.
Choice B is wrong because massaging your legs may not be enough to relieve the cramps, and may also cause more pain if done too hard or too fast.
Choice D is wrong because putting a cold compress on the calf of your leg may not be effective for leg cramps, and may also cause more discomfort or inflammation.
Leg cramps are common during pregnancy, especially in the second and third trimester.They are caused by various factors, such as pregnancy weight gain, changes in blood circulation, pressure on the nerves and blood vessels, nutrient deficiency, lack of exercise, or fluid buildup in your legs.To prevent or reduce leg cramps, you should drink plenty of water, stay active, eat a balanced diet rich in calcium, magnesium, and potassium, avoid standing or sitting for long periods of time, wear comfortable shoes and socks, and sleep on your left side with a pillow under or between your legs.
If leg cramps persist or become severe, you should consult your healthcare provider for possible treatment options.
Correct Answer is C
Explanation
This is because a normal fetal heart rate is between 110 and 160 beats per minute, and the range of 136 to 143 indicates that the fetus is well-oxygenated and not experiencing hypoxia or acidosis. The nurse should reassure the patient and explain that fetal movement may decrease during labor due to the pressure of the contractions on the uterus and the fetus.
Choice A is wrong because asking the patient about alcohol consumption is irrelevant and insensitive.
Alcohol can affect fetal development and growth, but it does not directly affect fetal movement or heart rate.
Choice B is wrong because bloody vaginal discharge, or bloody show, is a normal sign of cervical dilation and effacement during labor.
It does not indicate fetal distress or placental abruption.
Choice D is wrong because explaining the relationship between anxiety and fetal movement does not address the patient’s concern or provide any factual information.
Anxiety can affect maternal perception of fetal movement, but it does not cause fetal movement to decrease.
The nurse should validate the patient’s feelings and provide factual reassurance.
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