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
Logo

Nursing Elites

ATI LPN

Maternal Newborn ATI Quizlet

1. When assessing newborn reflexes, what action should be taken to elicit the Moro reflex?

Correct answer: A

Rationale: The correct answer is A: Perform a sharp hand clap near the infant. The Moro reflex, also known as the startle reflex, is elicited by a sudden stimuli such as a sharp hand clap near the infant. This reflex is characterized by the infant's arms extending and then flexing with a distinctive 'startle' motion. It is a normal and expected reflex in newborns, typically disappearing by 3-6 months of age. Choices B, C, and D are incorrect because they do not elicit the Moro reflex; holding the newborn vertically (choice B) or placing a finger at the base of the newborn's toes (choice C) are associated with other reflexes, while turning the newborn's head quickly to one side (choice D) is related to the tonic neck reflex.

2. A client is scheduled for a maternal serum alpha-fetoprotein test at 15 weeks of gestation. The client asks the nurse about the purpose of this test. What explanation should the nurse provide?

Correct answer: A

Rationale: The maternal serum alpha-fetoprotein (MSAFP) test is performed around 15-18 weeks of gestation to screen for neural tube defects and other developmental abnormalities in the fetus, not to assess fetal lung maturity, markers of fetal well-being, or Rh incompatibility between the mother and fetus. Choice A is the correct answer as it accurately reflects the purpose of the MSAFP test. Choices B, C, and D are incorrect because they do not align with the primary goal of this screening test.

3. A healthcare provider is preparing to administer vitamin K by IM injection to a newborn. The medication should be administered into which of the following muscles?

Correct answer: A

Rationale: Vitamin K is typically administered in the vastus lateralis muscle of a newborn to prevent bleeding disorders. The vastus lateralis muscle is the preferred site for IM injections in infants due to its size and accessibility, allowing for easy and safe administration. The ventrogluteal and dorsogluteal sites are more commonly used in adults due to better muscle mass and less risk of injury to nearby structures. The deltoid muscle is typically used for older children and adults for IM injections, as it is a well-developed muscle suitable for injections in these populations.

4. When reviewing postpartum nutrition needs with breastfeeding clients, which statement indicates an understanding of the teaching?

Correct answer: D

Rationale: The correct answer is D. Clients who do not like milk should continue taking calcium supplements to ensure they meet their increased calcium needs while breastfeeding. Calcium is essential for bone health, and during breastfeeding, the mother's calcium requirements are higher. While caffeine in coffee can be consumed in moderation, folic acid does not directly impact milk supply, and the additional 330 calories per day are recommended but not the focus of this question.

5. A healthcare professional is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the professional use to help minimize the pain of the procedure for the newborn?

Correct answer: D

Rationale: Placing the newborn skin-to-skin on the mother's chest is an effective technique to significantly decrease the newborn's pain level and anxiety during a heel stick procedure. This approach provides comfort, warmth, and familiarity to the newborn, promoting a sense of security and reducing distress. It is important for the healthcare professional to implement this technique before, during, and after the procedure to optimize pain management and support newborn well-being. The other options, such as applying a cool pack, requesting an IM analgesic prescription, and using a manual lancet, are not appropriate for minimizing pain in a newborn during a heel stick procedure. Applying a cool pack may cause vasoconstriction and increase pain, requesting an IM analgesic for a routine heel stick is excessive, and using a manual lancet without additional comforting measures may not adequately address the newborn's pain and anxiety.

Similar Questions

A client who is at 10 weeks of gestation reports abdominal pain and moderate vaginal bleeding, with a tentative diagnosis of inevitable abortion. Which of the following nursing interventions should be included in the plan of care?
A healthcare provider is instructing a client who is taking an oral contraceptive about manifestations to report. Which of the following manifestations should the healthcare provider include?
A client who is postpartum has a slightly boggy and displaced fundus to the right. Which of the following actions should the nurse take based on these findings?
When calculating the Apgar score of a newborn at 1 minute after delivery, which of the following findings would result in a score of 6?
A client gave birth 2 hours ago, and their blood pressure is 60/50 mm Hg. What action should the nurse take first?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses