Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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. Hold the newborn vertically allowing one foot to touch the table surface.
Hold the newborn vertically allowing one foot to touch the table surface:This action describes eliciting the Babinski reflex, not the Moro reflex. The Babinski reflex is elicited by stroking the sole of the foot, causing the toes to fan out and the big toe to dorsiflex while the other toes fan out.
B. Perform a sharp hand clap near the infant.
Perform a sharp hand clap near the infant:This action correctly describes eliciting the Moro reflex. The Moro reflex, also known as the startle reflex, is elicited by a sudden movement or loud noise near the infant. The infant responds by extending the arms outward, then bringing them together as if embracing.
C. Place a finger at the base of the newborn's toes.
Place a finger at the base of the newborn's toes: This action describes eliciting the plantar grasp reflex, not the Moro reflex. The plantar grasp reflex is elicited by stimulating the sole of the foot, causing the toes to curl downward in a grasping motion.
D. Turn the newborn's head quickly to one side.
Turn the newborn's head quickly to one side:This action describes eliciting the tonic neck reflex, also known as the fencing reflex, not the Moro reflex. The tonic neck reflex is elicited by turning the infant's head to one side while they are lying supine, causing the limbs on the side the head is turned toward to extend, and the limbs on the opposite side to flex.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Med Ati Med Surg Quiz Proctored Examquiz. Take the full exam now
Full Explanation
A) Hold the newborn vertically allowing one foot to touch the table surface:
This action describes eliciting the Babinski reflex, not the Moro reflex. The Babinski reflex is elicited by stroking the sole of the foot, causing the toes to fan out and the big toe to dorsiflex while the other toes fan out.
B) Perform a sharp hand clap near the infant:
This action correctly describes eliciting the Moro reflex. The Moro reflex, also known as the startle reflex, is elicited by a sudden movement or loud noise near the infant. The infant responds by extending the arms outward, then bringing them together as if embracing.
C) Place a finger at the base of the newborn's toes:
This action describes eliciting the plantar grasp reflex, not the Moro reflex. The plantar grasp reflex is elicited by stimulating the sole of the foot, causing the toes to curl downward in a grasping motion.
D) Turn the newborn's head quickly to one side:
This action describes eliciting the tonic neck reflex, also known as the fencing reflex, not the Moro reflex. The tonic neck reflex is elicited by turning the infant's head to one side while they are lying supine, causing the limbs on the side the head is turned toward to extend, and the limbs on the opposite side to flex.
Similar Questions
A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the following findings requires immediate intervention?
A. Fundal height below the umbilicus
Fundal height below the umbilicus:In the immediate postpartum period, the fundus typically descends at a predictable rate. A fundal height below the umbilicus on the first day postpartum is expected. It is not a cause for immediate intervention unless accompanied by other signs of postpartum hemorrhage.
B. Decreased urge to void
Decreased urge to void:A decreased urge to void is common in the immediate postpartum period due to perineal swelling, episiotomy or lacerations, and the effects of regional anesthesia. However, it is not an immediate concern as long as the client is voiding adequate amounts of urine.
C. Increased urine output
Increased urine output: Increased urine output in the postpartum period is expected due to the diuretic effect of the body eliminating excess fluid retained during pregnancy. It is not a cause for immediate intervention as long as the client is not exhibiting signs of dehydration.
D. Displaced fundus from the midline
Displaced fundus from the midline:A displaced fundus from the midline is concerning as it may indicate uterine atony, which is the most common cause of postpartum hemorrhage. Immediate intervention is necessary to prevent further complications such as excessive bleeding.
Full Explanation
A) Fundal height below the umbilicus:
In the immediate postpartum period, the fundus typically descends at a predictable rate. A fundal height below the umbilicus on the first day postpartum is expected. It is not a cause for immediate intervention unless accompanied by other signs of postpartum hemorrhage.
B) Decreased urge to void:
A decreased urge to void is common in the immediate postpartum period due to perineal swelling, episiotomy or lacerations, and the effects of regional anesthesia. However, it is not an immediate concern as long as the client is voiding adequate amounts of urine.
C) Increased urine output:
Increased urine output in the postpartum period is expected due to the diuretic effect of the body eliminating excess fluid retained during pregnancy. It is not a cause for immediate intervention as long as the client is not exhibiting signs of dehydration.
D) Displaced fundus from the midline:
A displaced fundus from the midline is concerning as it may indicate uterine atony, which is the most common cause of postpartum hemorrhage. Immediate intervention is necessary to prevent further complications such as excessive bleeding.
A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the following findings requires immediate intervention?
A. Fundal height below the umbilicus
Fundal height below the umbilicus:In the immediate postpartum period, the fundus typically descends at a predictable rate. A fundal height below the umbilicus on the first day postpartum is expected. It is not a cause for immediate intervention unless accompanied by other signs of postpartum hemorrhage.
B. Decreased urge to void
Decreased urge to void:A decreased urge to void is common in the immediate postpartum period due to perineal swelling, episiotomy or lacerations, and the effects of regional anesthesia. However, it is not an immediate concern as long as the client is voiding adequate amounts of urine.
C. Increased urine output
Increased urine output: Increased urine output in the postpartum period is expected due to the diuretic effect of the body eliminating excess fluid retained during pregnancy. It is not a cause for immediate intervention as long as the client is not exhibiting signs of dehydration.
D. Displaced fundus from the midline
Displaced fundus from the midline:A displaced fundus from the midline is concerning as it may indicate uterine atony, which is the most common cause of postpartum hemorrhage. Immediate intervention is necessary to prevent further complications such as excessive bleeding.
Full Explanation
A) Fundal height below the umbilicus:
In the immediate postpartum period, the fundus typically descends at a predictable rate. A fundal height below the umbilicus on the first day postpartum is expected. It is not a cause for immediate intervention unless accompanied by other signs of postpartum hemorrhage.
B) Decreased urge to void:
A decreased urge to void is common in the immediate postpartum period due to perineal swelling, episiotomy or lacerations, and the effects of regional anesthesia. However, it is not an immediate concern as long as the client is voiding adequate amounts of urine.
C) Increased urine output:
Increased urine output in the postpartum period is expected due to the diuretic effect of the body eliminating excess fluid retained during pregnancy. It is not a cause for immediate intervention as long as the client is not exhibiting signs of dehydration.
D) Displaced fundus from the midline:
A displaced fundus from the midline is concerning as it may indicate uterine atony, which is the most common cause of postpartum hemorrhage. Immediate intervention is necessary to prevent further complications such as excessive bleeding.
A nurse is teaching a client who is postpartum and has a new prescription for an injection of Rh, (D) Immunoglobulin. Which of the following should be included in the teaching?
A. It destroys Rh antibodies in mothers who are Rh negative.
It destroys Rh antibodies in mothers who are Rh negative:This statement is incorrect. Rh(D) Immunoglobulin, commonly known as RhoGAM, does not destroy Rh antibodies in mothers who are Rh negative. Instead, it prevents the mother's immune system from producing Rh antibodies against Rh-positive fetal blood cells.
B. It destroys Rh antibodies in newborns who are Rh positive.
It destroys Rh antibodies in newborns who are Rh positive:This statement is incorrect. Rh(D) Immunoglobulin does not destroy Rh antibodies in newborns. Its purpose is to prevent the formation of Rh antibodies in Rh-negative mothers, thus protecting future pregnancies from hemolytic disease of the newborn (HDN).
C. It prevents the formation of Rh antibodies in newborns who are Rh positive.
It prevents the formation of Rh antibodies in newborns who are Rh positive: This statement is incorrect. Rh(D) Immunoglobulin does not prevent the formation of Rh antibodies in newborns. It acts by suppressing the mother's immune response to Rh-positive fetal blood cells, thereby preventing the production of Rh antibodies that could harm future pregnancies.
D. It prevents the formation of Rh antibodies in mothers who are Rh negative.
It prevents the formation of Rh antibodies in mothers who are Rh negative:This statement is correct. Rh(D) Immunoglobulin is administered to Rh-negative mothers to prevent the formation of Rh antibodies in response to exposure to Rh-positive fetal blood cells during pregnancy or childbirth. By neutralizing fetal Rh-positive red blood cells in the maternal circulation, it prevents sensitization of the mother's immune system and protects future pregnancies from HDN.
Full Explanation
A) It destroys Rh antibodies in mothers who are Rh negative:
This statement is incorrect. Rh(D) Immunoglobulin, commonly known as RhoGAM, does not destroy Rh antibodies in mothers who are Rh negative. Instead, it prevents the mother's immune system from producing Rh antibodies against Rh-positive fetal blood cells.
B) It destroys Rh antibodies in newborns who are Rh positive:
This statement is incorrect. Rh(D) Immunoglobulin does not destroy Rh antibodies in newborns. Its purpose is to prevent the formation of Rh antibodies in Rh-negative mothers, thus protecting future pregnancies from hemolytic disease of the newborn (HDN).
C) It prevents the formation of Rh antibodies in newborns who are Rh positive:
This statement is incorrect. Rh(D) Immunoglobulin does not prevent the formation of Rh antibodies in newborns. It acts by suppressing the mother's immune response to Rh-positive fetal blood cells, thereby preventing the production of Rh antibodies that could harm future pregnancies.
D) It prevents the formation of Rh antibodies in mothers who are Rh negative:
This statement is correct. Rh(D) Immunoglobulin is administered to Rh-negative mothers to prevent the formation of Rh antibodies in response to exposure to Rh-positive fetal blood cells during pregnancy or childbirth. By neutralizing fetal Rh-positive red blood cells in the maternal circulation, it prevents sensitization of the mother's immune system and protects future pregnancies from HDN.