Nokea
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?
- A. Place a finger at the base of the newborn’s toes.
- B. Turn the newborn’s head quickly to one side.
- C. Hold the newborn vertically allowing one foot to touch the table surface.
- D. Perform a sharp hand clap near the infant.
Correct Answer: D
Rationale: The Moro reflex is a startle reflex observed in newborns. To elicit this reflex, a sudden loud noise or movement is needed. Performing a sharp hand clap near the infant is the appropriate action to trigger the Moro reflex. This action mimics a sudden loud noise, causing the baby to extend the arms and legs, then bring them back in a hugging motion. Placing a finger at the base of the newborn's toes (Choice A) does not elicit the Moro reflex. Turning the newborn's head quickly to one side (Choice B) triggers the asymmetric tonic neck reflex, not the Moro reflex. Holding the newborn vertically allowing one foot to touch the table surface (Choice C) elicits the stepping reflex, not the Moro reflex.
You may also like to solve these questions
A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client?
- A. Rapid decline in human chorionic gonadotropin (hCG) levels
- B. Irregular fetal heart rate
- C. Excessive uterine enlargement
- D. Profuse, clear vaginal discharge
Correct Answer: C
Rationale: The correct answer is C: Excessive uterine enlargement. A hydatidiform mole is a gestational trophoblastic disease characterized by abnormal growth of placental tissue in the uterus, leading to excessive uterine enlargement. This condition results in the absence of a viable fetus and can cause symptoms such as vaginal bleeding, severe nausea, and hypertension. The other choices are incorrect because: A) Rapid decline in hCG levels is not a typical finding in a hydatidiform mole, as hCG levels are usually elevated. B) Irregular fetal heart rate is not applicable in this case since there is no viable fetus. D) Profuse, clear vaginal discharge is not a characteristic symptom of a hydatidiform mole. E, F, and G are not provided as options.
A nurse is assessing a newborn who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect?
- A. Inwardly turned foot on the affected side
- B. Absent plantar reflexes
- C. Lengthened thigh on the affected side
- D. Asymmetric thigh folds
Correct Answer: D
Rationale: The correct answer is D: Asymmetric thigh folds. In DDH, there is an abnormal formation of the hip joint which can lead to dislocation. Asymmetric thigh folds result from the shortened thigh muscles on the affected side due to the dislocation. This finding is indicative of DDH as it reflects the displacement of the femoral head. The other choices are incorrect because an inwardly turned foot (A) is associated with clubfoot, absent plantar reflexes (B) may indicate neurological issues, and a lengthened thigh (C) is not a typical finding in DDH.
A nurse is assessing a newborn 1 hour after birth. Which of the following respiratory rates is within the expected reference range for a newborn?
- A. 48/min
- B. 22/min
- C. 100/min
- D. 110/min
Correct Answer: A
Rationale: The correct answer is A: 48/min. The normal respiratory rate for a newborn is typically between 30-60 breaths per minute. Choice A falls within this range, indicating a normal respiratory rate for the newborn. Choices B, C, and D are outside the expected reference range. Choice B (22/min) is too low, while choices C (100/min) and D (110/min) are too high, which could indicate respiratory distress or other underlying issues in the newborn. It is important for the nurse to monitor the newborn closely and further assess if the respiratory rate is outside the normal range.
A nurse in the ambulatory surgery center is providing discharge teaching to a client who had a dilation and curettage (D&C) following a spontaneous miscarriage. Which of the following should be included in the teaching?
- A. Products of conception will be present in vaginal bleeding.
- B. Increased intake of zinc-rich foods is recommended.
- C. Vaginal intercourse can be resumed after 2 weeks.
- D. Aspirin may be taken for cramps.
Correct Answer: C
Rationale: The correct answer is C: Vaginal intercourse can be resumed after 2 weeks. This is important to prevent infection and allow the cervix to heal. Choice A is incorrect as products of conception are typically expelled during the D&C procedure. Choice B is irrelevant as zinc intake is not directly related to post-D&C care. Choice D is incorrect as aspirin can increase the risk of bleeding post-D&C.
A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider?
- A. Dyspnea
- B. Headaches
- C. Nervousness
- D. Tremors
Correct Answer: A
Rationale: The correct answer is A: Dyspnea. Terbutaline is a beta-adrenergic agonist that can cause pulmonary edema as a serious adverse effect. Dyspnea is a common symptom of pulmonary edema, indicating potential respiratory distress. This adverse effect should be reported promptly to the provider for further evaluation and management to prevent complications.
Incorrect choices:
B: Headaches - Headaches are a common side effect of terbutaline but are not as concerning as respiratory distress.
C: Nervousness - Nervousness is a common side effect of terbutaline and does not typically require immediate reporting unless severe.
D: Tremors - Tremors are a common side effect of terbutaline and are not as concerning as respiratory distress.