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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

The correct answer is choice C. Auscultate the fetal heart sounds.This is because spontaneous rupture of membranes (SROM) may be associated with fetal distress or cord prolapse, and the nurse should assess the fetal well-being as soon as possible.Fetal heart sounds can indicate the presence of fetal bradycardia, tachycardia, or decelerations, which may require immediate intervention.

Choice A is wrong because checking the specific gravity of the amniotic fluid is not a priority action after SROM.The specific gravity can help differentiate amniotic fluid from urine, but it is not as reliable as other methods such as nitrazine paper test or visual inspection.

Choice B is wrong because providing dry linens for the patient is a comfort measure, but not a priority action after SROM.The nurse should first ensure the safety of the fetus and the mother before attending to their comfort needs.

Choice D is wrong because notifying the health care provider is an important action after SROM, but not the first one.The nurse should gather relevant data such as fetal heart rate, maternal vital signs, and characteristics of the fluid before contacting the provider.

A. Sole creases that cover only the anterior one-third of the foot. B. Abundance of vernix caseosa in the skin creases. C. Dryness and flaking of the skin on the hands and feet. D. Large amount of fine, downy hair on the back and shoulders.

Correct Answer is C

Explanation

The correct answer is choice C. Dryness and flaking of the skin on the hands and feet.This is because a newborn with a gestational age of 42 weeks is considered post-mature and has lost the protective vernix caseosa that covers the skin of most newborns.The skin of a post-mature newborn is also more exposed to the amniotic fluid, which can cause it to peel and crack.

Choice A is wrong because sole creases that cover only the anterior one-third of the foot are characteristic of a preterm newborn, not a post-mature one.

Choice B is wrong because vernix caseosa is abundant in preterm newborns and decreases as gestational age increases.A post-mature newborn would have little or no vernix caseosa on the skin.

Choice D is wrong because a large amount of fine, downy hair (lanugo) on the back and shoulders is also typical of a preterm newborn, not a post-mature one.Lanugo usually disappears by 36 weeks of gestation.A post-mature newborn would have little or no lanugo on the body.

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When assessing a newborn, which is the best method for the nurse to use to elicit the Moro reflex?

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Naxlex Comprehensive Predictor Exams

A patient states, “My water just broke.” The nurse verifies that her membranes have ruptured spontaneously. Which action should the nurse take next?

Correct Answer is C

Explanation

A nurse is caring for a newborn with a gestational age of 42 weeks. Which finding would the nurse expect during the assessment of this newborn?

Correct Answer is C

Explanation

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