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

This is because pregnancy-induced hypertension (PIH) can cause eclampsia, a condition characterized by seizures and coma.Eclampsia can occur during pregnancy, labor, or postpartum.

A nurse should monitor the client for signs of increased blood pressure, headache, blurred vision, epigastric pain, and hyperreflexia, which may indicate an impending convulsion.

Choice A is wrong because hemorrhage is not a common complication of PIH.

Hemorrhage may occur due to other causes such as uterine atony, lacerations, or retained placenta.

Choice B is wrong because urinary retention is not a common complication of PIH.

Urinary retention may occur due to other causes such as anesthesia, trauma, or infection.

Choice D is wrong because thrombophlebitis is not a common complication of PIH.

Thrombophlebitis is a condition where a blood clot forms in a vein and causes inflammation.

It may occur due to other risk factors such as immobility, dehydration, or injury.

A. Plan to remain flat in bed for six hours after the test. B. Expect some vaginal bleeding after the test. C. Empty your bladder prior to the test. D. Do not consume any solid foods for sixteen hours prior to the test.

Correct Answer is C

Explanation

The correct answer is choice C. Empty your bladder prior to the test.This is because a full bladder can interfere with the insertion of the needle and increase the risk of complications.Amniocentesis is a test that involves removing and testing a small sample of cells from amniotic fluid, the fluid that surrounds the baby in the womb.It is done to check for genetic or chromosomal conditions, such as Down’s syndrome, Edwards’ syndrome or Patau’s syndrome.

Choice A is wrong because there is no need to remain flat in bed for six hours after the test.You can resume your normal activities after a few hours of rest.

Choice B is wrong because vaginal bleeding is not a normal outcome of amniocentesis.If you experience any bleeding, leaking of fluid, fever or severe pain after the test, you should contact your doctor immediately.

Choice D is wrong because there is no restriction on eating before the test.You can have your normal meals and drinks before amniocentesis.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who had pregnancy-induced hypertension (PIH) is now postpartum. A nurse should closely monitor this client for which complication?

Correct Answer is C

Explanation

A patient is scheduled for an amniocentesis when she is 18 weeks pregnant. Which instruction concerning amniocentesis should the nurse give to the patient?

Correct Answer is C

Explanation

A client who is two weeks postpartum calls the office and tells a nurse, "l am having a small amount of brownish discharge from my vagina." Which response is appropriate for the nurse to make?

A patient who is 37 weeks pregnant and has gestational diabetes is admitted to the labor and delivery unit for induction. The patient is placed on an external fetal monitor and receives an epidural anesthesia.Which action should the nurse take to identify a potential side effect of the epidural?

A nurse is caring for a client with postpartum hemorrhage. The provider has ordered Methylergonovine 200 mcg intravenously to be administered stat. The nurse should perform which priority assessment prior to administering this medication?

A patient who is 38 weeks pregnant is admitted to the hospital in active labor. On admission, the patient says, “For the past ten hours, I have been leaking small amounts of urine.” Which action should the nurse take initially?

The nurse suspects drug abuse in a patient admitted with no prenatal care and a diagnosis of abruptio placentae.Which question would elicit the most information from the patient concerning the suspected drug use?

When a pregnant patient has genital herpes, for which complication is the patient at higher risk than the general population?

The mother visits her infant in the nursery. The nurse shows the mother how to place her finger in the palm of the baby’s hand so that the baby will squeeze her finger.This behavior on the nurse’s part reflects an understanding of which principle?

The mother of a 4-hour-old newborn reports to a nurse, “My son is producing breast milk.” The nurse’s response should be based on which understanding about newborn physiology? This is:.