Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assisting to collect data for a gestational age assessment on a newborn. Which of the following should the nurse check during a neuromuscular assessment? (Select all that apply.)
A. Heel to ear
Heel to ear is a test that measures the flexibility of the newborn's hip and knee joints. The nurse should gently flex the newborn's hip and knee and bring the foot toward the ear on the same side. The closer the foot is to the ear, the higher the score. This test is part of the neuromuscular assessment for gestational age.
B. Popliteal angle
Popliteal angle is a test that measures the angle of flexion at the knee joint. The nurse should flex the newborn's hip and knee at 90 degrees and then extend the lower leg until resistance is felt. The smaller the angle, the higher the score. This test is also part of the neuromuscular assessment for gestational age.
C. Moro reflex
Moro reflex is a test that evaluates the newborn's startle response. The nurse should hold the newborn in a semi-sitting position and then allow the head to fall back slightly. The newborn should extend and abduct the arms and legs, then flex and adduct them. This test is not part of the neuromuscular assessment for gestational age, but rather a reflex assessment for neurological function.
D. Scarf sign
Scarf sign is a test that measures the flexibility of the newborn's shoulder and elbow joints. The nurse should draw one of the newborn's arms across the chest toward the opposite shoulder. The farther the elbow can be moved across the body, the lower the score. This test is part of the neuromuscular assessment for gestational age.
E. Arm recoil
Arm recoil is a test that measures the degree of flexion at the elbow joint. The nurse should extend both of the newborn's arms for 5 seconds and then release them. The arms should return to a flexed position quickly and fully. The faster and more complete the recoil, the higher the score. This test is part of the neuromuscular assessment for gestational age.
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Full Explanation
Choice A reason:
Heel to ear is a test that measures the flexibility of the newborn's hip and knee joints. The nurse should gently flex the newborn's hip and knee and bring the foot toward the ear on the same side. The closer the foot is to the ear, the higher the score. This test is part of the neuromuscular assessment for gestational age.
Choice B reason:
Popliteal angle is a test that measures the angle of flexion at the knee joint. The nurse should flex the newborn's hip and knee at 90 degrees and then extend the lower leg until resistance is felt. The smaller the angle, the higher the score. This test is also part of the neuromuscular assessment for gestational age.
Choice C reason:
Moro reflex is a test that evaluates the newborn's startle response. The nurse should hold the newborn in a semi-sitting position and then allow the head to fall back slightly. The newborn should extend and abduct the arms and legs, then flex and adduct them. This test is not part of the neuromuscular assessment for gestational age, but rather a reflex assessment for neurological function. •
Choice D reason:
Scarf sign is a test that measures the flexibility of the newborn's shoulder and elbow joints. The nurse should draw one of the newborn's arms across the chest toward the opposite shoulder. The farther the elbow can be moved across the body, the lower the score. This test is part of the neuromuscular assessment for gestational age.
Choice E reason:
Arm recoil is a test that measures the degree of flexion at the elbow joint. The nurse should extend both of the newborn's arms for 5 seconds and then release them. The arms should return to a flexed position quickly and fully. The faster and more complete the recoil, the higher the score. This test is part of the neuromuscular assessment for gestational age.
Similar Questions
What causes congenital hip dysplasia?
A. Using illicit drugs
Using illicit drugs is not a known cause of congenital hip dysplasia. Illicit drugs may have other harmful effects on the baby, but they do not affect the formation of the hip joint.
B. Unknown
The exact cause of congenital hip dysplasia is not clear. Both genetic and environmental factors seem to play a role in the development of the disorder. Some risk factors include being female, firstborn, breech position, family history, and tight swaddling.
C. Being in nursing school
Being in nursing school is not a cause of congenital hip dysplasia. This is an irrelevant and incorrect choice.
D. Drinking too much.
Drinking too much is not a cause of congenital hip dysplasia. Alcohol consumption during pregnancy may increase the risk of fetal alcohol syndrome and other complications, but it does not affect the formation of the hip joint.
Full Explanation
Choice A reason:
Using illicit drugs is not a known cause of congenital hip dysplasia. Illicit drugs may have other harmful effects on the baby, but they do not affect the formation of the hip joint.
Choice B reason:
Unknown. The exact cause of congenital hip dysplasia is not clear. Both genetic and environmental factors seem to play a role in the development of the disorder. Some risk factors include being female, firstborn, breech position, family history, and tight swaddling.
Choice C reason:
Being in nursing school is not a cause of congenital hip dysplasia. This is an irrelevant and incorrect choice.
Choice D reason:
Drinking too much is not a cause of congenital hip dysplasia. Alcohol consumption during pregnancy may increase the risk of fetal alcohol syndrome and other complications, but it does not affect the formation of the hip joint.
What should be included in teaching for bottle-feeding parents? (Select all that apply.)
A. Discard unused formula in used bottle after 2 hours
Once a baby has started drinking from a bottle, bacteria from the baby’s mouth can contaminate the formula. Any leftover formula should be discarded after 2 hours to prevent bacterial growth and reduce the risk of infection.
B. Never prop a bottle
Propping a bottle can lead to choking, ear infections, and dental issues (such as baby bottle tooth decay). Babies should always be held upright during feedings.
C. Formula is available in three forms.
Infant formula is available in three types: Ready-to-feed (no mixing needed), Liquid concentrate (mix with water),Powdered formula (mix with water).
D. Warm the bottle in the microwave
Microwaving heats unevenly, creating hot spots that can burn the baby’s mouth. Instead, warm bottles by placing them in warm water for a few minutes and always test the temperature on the wrist before feeding.
E. Store prepared bottles in the refrigerator
If formula is prepared in advance, it must be stored in the refrigerator (≤ 4°C or 40°F) and used within 24 hours to prevent bacterial growth.
Full Explanation
A. Discard unused formula in used bottle after 2 hours: Once a baby has started drinking from a bottle, bacteria from the baby’s mouth can contaminate the formula. Any leftover formula should be discarded after 2 hours to prevent bacterial growth and reduce the risk of infection.
B. Never prop a bottle: Propping a bottle can lead to choking, ear infections, and dental issues (such as baby bottle tooth decay). Babies should always be held upright during feedings.
C. Formula is available in three forms: Infant formula is available in three types: Ready-to-feed (no mixing needed), Liquid concentrate (mix with water),Powdered formula (mix with water).
E. Store prepared bottles in the refrigerator: If formula is prepared in advance, it must be stored in the refrigerator (≤ 4°C or 40°F) and used within 24 hours to prevent bacterial growth.
Incorrect Answer:
D. Warm the bottle in the microwave: Microwaving heats unevenly, creating hot spots that can burn the baby’s mouth. Instead, warm bottles by placing them in warm water for a few minutes and always test the temperature on the wrist before feeding.
The LPN is discussing childbirth classes with a patient who is 30 weeks gestation. The patient shares that she hopes to deliver a baby who is awake and alert. The LPN is aware of Lamaze and Bradley classes being offered. For which reasons would the LPN recommend Bradley classes to this patient? Select all that apply.
A. The Bradley method teaches the labor partner how to coach and support the mother during labor.
The Bradley method teaches the labor partner how to coach and support the mother during labor. This is true because the Bradley method emphasizes the role of the partner as an active participant and a skilled coach who can help the mother relax, breathe, and cope with pain during labor. The partner also serves as an advocate for the mother's preferences and needs in the hospital setting.
B. The Bradley method teaches the mother and partner about the variety of methods to control pain.
The Bradley method teaches the mother and partner about the variety of methods to control pain. This is false because the Bradley method does not teach a variety of methods to control pain, but rather focuses on relaxation as the main way to reduce pain during labor. The Bradley method also discourages the use of medication or medical interventions for pain relief, unless they are medically necessary.
C. The Bradley method prepares the woman to deliver without medical interventions and medications.
The Bradley method prepares the woman to deliver without medical interventions and medications. This is true because the Bradley method aims to help women have an unmedicated birth with minimal medical intervention. The Bradley method teaches women how to avoid unnecessary interventions and how to cope with natural labor by using relaxation, breathing, nutrition, and exercise. The Bradley method also educates women on how to reduce their risk of having a C-section and what to do if it becomes medically necessary.
D. The Bradley method focuses on muscle control because muscle tension increases the pain of labor.
The Bradley method focuses on muscle control because muscle tension increases the pain of labor. This is false because the Bradley method does not focus on muscle control, but rather on deep and complete relaxation during labor. The Bradley method believes that muscle tension interferes with the natural process of labor and increases pain, so it teaches women how to relax their muscles and let their body do the work.
E. The Bradley method is the most widely used method in the US.
The Bradley method is the most widely used method in the US. This is false because the Bradley method is not the most widely used method in the US, but rather one of several options for natural childbirth. According to a 2017 survey by Listening to Mothers, only 4% of women reported using the Bradley method for their most recent birth, compared to 48% who used Lamaze, 14% who used hypnobirthing, and 9% who used other methods.