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. This action elicits the Moro reflex by stimulating the startle response. The Moro reflex involves the baby's arms spreading out and then coming back in when they feel like they are falling. This reflex helps in assessing the baby's neurological development. Choices B, C, and D do not specifically target the Moro reflex and may elicit other reflexes or responses. Holding the newborn vertically (B) may trigger the stepping reflex, placing a finger at the base of the toes (C) may provoke the Babinski reflex, and turning the newborn's head (D) may elicit the tonic neck reflex.

Correct Answer: A

Rationale: The correct answer is A: Increased blood pressure in the arms with decreased blood pressure in the legs. Coarctation of the aorta causes narrowing of the aorta, leading to increased blood pressure in the arms due to the pressure build-up before the narrowing and decreased blood pressure in the legs due to reduced blood flow beyond the narrowing. This pressure difference is a classic clinical manifestation of coarctation of the aorta. Choices B, C, and D are incorrect because they do not align with the pathophysiology of coarctation of the aorta. B is incorrect as decreased blood pressure in the arms is not typical. C is incorrect as increased blood pressure in both the arms and legs does not reflect the characteristic pressure difference caused by the aortic narrowing. D is incorrect as decreased blood pressure in both the arms and legs is not consistent with the presentation of coarctation of the aorta.

Correct Answer: B

Rationale: The correct answer is B because Kegel exercises help strengthen the pelvic floor muscles, which can aid in pelvic muscle stretching during birth. This can potentially reduce the risk of pelvic floor dysfunction postpartum. A is incorrect because Kegel exercises do not directly prevent constipation. C is incorrect because while Kegel exercises may indirectly help with backaches by improving pelvic floor muscle support, they are not specifically targeted for backache relief. D is incorrect as Kegel exercises do not prevent stretch marks, as stretch marks are related to skin elasticity rather than muscle tone.

Correct Answer: B

Rationale: The correct answer is B: A surge of energy. This is a sign that precedes labor as the body may experience a burst of energy known as the "nesting instinct." This surge can occur as the body prepares for the upcoming physical demands of labor. A: Decreased vaginal discharge is not a sign of impending labor; in fact, there may be an increase in vaginal discharge as the body prepares for childbirth. C: Urinary retention is not a sign of impending labor and can be a symptom of other issues such as a urinary tract infection. D: Weight gain of 0.5 to 1.5 kg is not a specific sign of labor approaching; weight fluctuations during pregnancy are common and can vary based on various factors.

Correct Answer: A

Rationale: The correct action for the nurse to take first is to evaluate the firmness of the uterus. This is because the client's low blood pressure may indicate postpartum hemorrhage, which is a common complication after childbirth. Assessing the firmness of the uterus helps determine if there is uterine atony, a leading cause of postpartum hemorrhage. By addressing uterine atony promptly, the nurse can prevent further blood loss and stabilize the client's condition. Summary: - Option B, initiating oxygen therapy, is not the first priority as the client's low blood pressure is likely due to hemorrhage rather than hypoxemia. - Option C, administering oxytocin infusion, may be necessary to address uterine atony but should only be done after assessing the firmness of the uterus. - Option D, obtaining a type and crossmatch, is important for potential blood transfusion but is not the immediate priority compared to assessing for uterine atony.