When checking for the Moro reflex in a newborn, what action should the nurse take?

Correct Answer: D

Rationale: The correct answer is D because the Moro reflex is elicited by sudden head movement or loud noise, causing the infant to extend their arms, then bring them back in a hugging motion. By holding the newborn in a semi-sitting position and allowing their head and trunk to fall backward, the nurse can observe the Moro reflex. Choices A, B, and C do not correctly elicit the Moro reflex as they involve different stimuli or movements that do not trigger the characteristic response of arm extension followed by flexion.

Correct Answer: C

Rationale: Rationale: - MSAFP screening is recommended for all pregnant clients to assess risk of neural tube defects or chromosomal abnormalities. - It is a standard prenatal test regardless of specific medical conditions. - Options A, B, and D are not directly related to the indication for MSAFP screening in pregnancy.

Correct Answer: A

Rationale: The correct answer is A: Peanut butter. Phenylketonuria (PKU) is a metabolic disorder where the body can't process phenylalanine found in protein foods. Peanut butter is high in protein and contains phenylalanine, so it should be eliminated from the client's diet. Potatoes, apple juice, and broccoli are low in protein and do not contain high levels of phenylalanine, so they do not need to be eliminated. It is crucial for the client to avoid foods high in phenylalanine to prevent the buildup of toxic levels in the body, which can lead to serious health issues.

Correct Answer: B

Rationale: The correct answer is B: Your son is displaying an adverse sibling response. This is the correct answer because the 4-year-old's regression in toilet training is likely a response to the recent birth of a new sibling. This behavior is common as the older child may feel jealous or neglected, leading to regression. Providing this statement will help the client understand the underlying cause of the behavior and address it appropriately. Incorrect choices: A: This choice suggests the child was not ready for toilet training, which is not the primary issue here. C: Counseling may be beneficial in some cases but is not the first-line intervention for this situation. D: Enrolling in preschool may not directly address the underlying cause of the behavior, which is related to the new sibling.

Correct Answer: D

Rationale: The correct answer is D: Epstein's pearls. These small pearly white nodules are commonly found on the roof of newborns' mouths and are considered a normal finding. They are formed from trapped epithelial cells during the development of the baby's mouth. They are harmless and typically resolve on their own without treatment. A: Mongolian spots are bluish-black or bruise-like markings found on the skin, not in the mouth. B: Milia spots are small, white, raised bumps on the skin, not found in the mouth. C: Erythema toxicum is a common benign rash in newborns, not related to the mouth. In summary, Epstein's pearls are the correct answer due to their specific location in the newborn's mouth, their appearance, and the fact that they are a normal finding in newborns. The other choices are incorrect as they describe different conditions not related to the oral cavity.

Correct Answer: C

Rationale: Rationale: C is correct because keeping the nipple full of formula throughout the feeding helps prevent the baby from swallowing air, reducing the risk of gas and colic. A is incorrect because burping should be done mid-feeding. B is incorrect because newborns should be held in an upright position while feeding to prevent choking. D is incorrect because unused formula should be discarded within 1-2 hours, not refrigerated.

Correct Answer: C

Rationale: The correct answer is C: Erythromycin. Erythromycin is the standard treatment for preventing ophthalmia neonatorum, a condition caused by Neisseria gonorrhoeae or Chlamydia trachomatis. It is a broad-spectrum antibiotic that effectively prevents bacterial infections in newborns. Ofloxacin (A) is a fluoroquinolone antibiotic not typically used in newborns. Nystatin (B) is an antifungal medication used for treating fungal infections, not bacterial infections like ophthalmia neonatorum. Ceftriaxone (D) is a cephalosporin antibiotic used for various bacterial infections, but it is not the first-line treatment for preventing ophthalmia neonatorum.

Correct Answer: D

Rationale: The correct answer is D: Position the newborn skin-to-skin on the client's chest. This promotes bonding through touch, warmth, and smell, stimulating the release of oxytocin in both the parent and the infant. Skin-to-skin contact enhances attachment, regulates the newborn's temperature and breathing, and supports breastfeeding initiation. A: Encouraging parents to touch and explore the newborn's features is important but not as crucial as immediate skin-to-skin contact for bonding and physiological benefits. B: Limiting noise and interruptions can create a calm environment but does not directly promote bonding like skin-to-skin contact. C: Placing the newborn at the client's breast is beneficial for breastfeeding initiation but may not provide the same level of closeness and comfort as skin-to-skin contact.

Correct Answer: A

Rationale: The correct answer is A: Oxygen saturation. Monitoring oxygen saturation is crucial in evaluating the newborn's respiratory status post-surfactant administration. It helps assess the effectiveness of surfactant therapy in improving oxygenation. Body temperature and serum bilirubin are not directly related to assessing respiratory distress syndrome. Heart rate may be affected by various factors and may not provide specific information on respiratory status.