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?
Explanation & Rationale
Choice A rationalePerforming a sharp hand clap near the infant activates the Moro reflex, a startle response present at birth that integrates by around six months of age. The reflex involves symmetric extension and abduction of the arms followed by flexion, demonstrating proper neurological function.Choice B rationalePlacing a finger at the base of the newborn's toes elicits the plantar grasp reflex, not the Moro reflex. This reflex involves flexion of the toes when pressure is applied to the sole and is unrelated to startling the infant.Choice C rationaleHolding the newborn vertically allowing one foot to touch the table surface elicits the stepping reflex, not the Moro reflex. This reflex involves simulated walking movements and is unrelated to assessing startle responses.Choice D rationaleTurning the newborn's head quickly to one side elicits the tonic neck reflex (fencing reflex) rather than the Moro reflex. This reflex involves extension of the limbs on the side the head is turned and flexion on the opposite side. .