A newborn's birth was prolonged because the shoulders were very wide. The nurse performing the assessment would be particularly observant for a problem with the:

Correct Answer: A

Rationale: The Moro reflex is a normal infantile reflex that is typically present at birth and disappears around 4-6 months of age. This reflex is triggered by a sudden loss of support or a loud noise, causing the infant to throw back the head and extend the arms in a gesture as if trying to grab something. In a situation where the newborn's birth was prolonged due to wide shoulders, there is a higher risk of injury to the brachial plexus (nerves that control arm movement) during delivery. Damage to the brachial plexus can result in weakness or paralysis of the affected arm, and this may impact the Moro reflex as it involves the arms' movement. Therefore, the nurse would be particularly observant for any abnormality or lack of response in the Moro reflex as it may indicate potential nerve injury related to the difficult birth.

Correct Answer: D

Rationale: Vastus lateralis muscle is the recommended site due to its size and safety.

Correct Answer: A

Rationale: Preterm labor is diagnosed based on a combination of factors including gestational age (typically less than 37 weeks), uterine activity (regular, painful contractions), and progressive changes in the cervix (dilation, effacement, or both). It is important for the nurse to be aware of these criteria to promptly recognize and manage preterm labor to reduce the risk of complications for both the mother and the baby. Early detection and timely intervention can help improve outcomes for preterm infants.

Correct Answer: A

Rationale: Proper technique ensures accurate detection of abnormalities.

Correct Answer: B

Rationale: A headache unrelieved by rest or medication may indicate preeclampsia or other serious conditions and should be reported immediately.