A nurse in the newborn nursery is collecting data about a newborn's Moro reflex. Which of the following actions should the nurse take to elicit this reflex?
A. Turn the newborn's head quickly to one side while they are sleeping. B. Place a finger in the newborn's palm. C. Clap hands after laying the newborn on a flat surface. D. Hold the newborn upright with one foot touching the crib surface
Answer and Explanation
The Correct Answer is A
A. Turning the newborn's head quickly to one side while they are sleeping is the correct action to elicit the Moro reflex. This reflex is a startle reflex characterized by the newborn's arms and legs extending outward and then quickly retracting when they feel as if they are falling.
B. Placing a finger in the newborn's palm elicits the grasp reflex, not the Moro reflex.
C. Clapping hands after laying the newborn on a flat surface does not directly elicit the Moro reflex.
D. Holding the newborn upright with one foot touching the crib surface does not elicit the Moro reflex.
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Related Questions
Correct Answer is B
Explanation
A. Asking about the current President of the United States assesses the client's orientation to time and place but does not directly assess abstract thinking.
B. Asking what the phrase 'butterflies in my stomach' means assesses the client's ability to
interpret and understand abstract concepts, as it requires the client to interpret a metaphorical expression.
C. Asking the client to count backward from 20 to 1 assesses attention and concentration but does not directly assess abstract thinking.
D. Asking the client to draw a clock that shows the hands at 4:30 assesses cognitive function, spatial orientation, and memory but does not directly assess abstract thinking.
Correct Answer is C
Explanation
A. Encouraging the client to gain 2.3 kg (5 lb) per week is not appropriate for a client with anorexia nervosa. Rapid weight gain can lead to medical complications and may contribute to the client's anxiety and resistance to treatment.
B. While monitoring the client for a period after meals may be appropriate to observe for signs of purging behaviors, weighing the client each morning after voiding is a more critical intervention for assessing changes in weight, which is often a key indicator of nutritional status and progress in treatment for anorexia nervosa.
C. Weighing the client each morning after voiding allows for accurate monitoring of weight changes, which are crucial in assessing nutritional status and response to treatment in clients with anorexia nervosa.
D. Reinforcing teaching about healthy eating during meals is important, but it is not the priority intervention in the acute phase of treatment for anorexia nervosa. Ensuring accurate and regular weight monitoring is more critical for assessing progress and determining the effectiveness of interventions.
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