Newborn Reflexes > Maternal & Newborn
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Summary
Total Questions : 15
Showing 15 questions, Sign in for moreA nurse is performing a routine assessment on a newborn.
The nurse gently drops the head of the newborn while supporting the body and observes symmetric abduction and extension of the arms followed by flexion and adduction of the arms.
This finding indicates a positive response for which of the following reflexes?
Explanation
This reflex is also known as the startle reflex and it is a protective reaction to a loud noise or sudden movement.When an abrupt sound startles the baby or their head falls backward, they extend their arms and legs, then flex and adduct their arms.
A nurse is assessing a newborn’s reflexes as part of a neurologic examination.
The nurse strokes the outer edge of the sole of the newborn’s foot from heel to toe and observes that the newborn’s toes fan upward and out.
The nurse documents this as a positive response for which of the following reflexes?
Explanation
This is a normal reflex in newborns that disappears by 12 to 18 months of age.
It indicates that the nervous system is developing properly.
The Babinski reflex is elicited by stroking the outer edge of the sole of the foot from heel to toe and observing the movement of the toes.
A nurse is performing a routine assessment on a newborn.
The nurse strokes the cheek of the newborn and notes that the newborn turns toward that side and opens his mouth.
The nurse documents this finding as which of the following?
Explanation
This reflex starts when the corner of the baby’s mouth is stroked or touched.
The baby will turn his or her head and open his or her mouth to follow and root in the direction of the stroking.This helps the baby find the breast or bottle to start feeding.This reflex lasts about 4 months.
A nurse is caring for a 2-month-old infant who has a positive Moro reflex.
Which of the following actions should the nurse take to elicit this reflex? (Select all that apply.)
Explanation
To elicit the Moro reflex, the nurse should hold the infant in a semi-sitting position and let the head drop back slightly.This will simulate the sensation of falling and trigger the reflex, which involves spreading out the arms, pulling them in, and crying
A nurse is performing a neurological assessment on a newborn.
Which of the following reflexes should disappear by 8 months of age? (Select all that apply.)
Explanation
The Moro reflex, Babinski reflex and palmar grasp reflex are all newborn reflexes that should disappear by 8 months of age.These reflexes are involuntary responses to certain stimuli that indicate the normal development and function of the brain and nervous system.
A nurse is teaching a group of parents about infant reflexes.
Which of the following statements by a parent indicates an understanding of the teaching?
Explanation
This statement indicates an understanding of the teaching because it accurately describes the duration of the plantar grasp reflex in infants.
The plantar grasp reflex is when the toes flex and adduce when the sole of the foot is stimulated.It is usually present at or soon after birth and disappears between 6 and 12 months of age.
A nurse is teaching a group of new parents about infant reflexes.
Which of the following statements should the nurse include in the teaching? (Select all that apply.)
Explanation
The Moro reflex, or startle reflex, is an involuntary response to a sudden loss of support or a loud noise that involves spreading and curling the arms and legs.
The Moro reflex involves three distinct components: spreading out the arms (abduction), pulling the arms in (adduction), and crying (usually). The baby may also extend and flex their legs.
The Moro reflex can be used to assess the integrity of the baby’s nervous system, as it reflects the development and function of the brain stem. Absence, asymmetry, or persistence of the Moro reflex may indicate neurological problems.
A nurse is evaluating a 3-month-old baby for developmental milestones.
Which of the following findings should the nurse report to the provider as a possible concern?
Explanation
Smiling at familiar faces is a social and emotional milestone that a 3-month-old baby should be able to achieve.
It indicates that the baby recognizes and responds to people they know and trust.A lack of smiling or eye contact may be a sign of developmental delay or autism spectrum disorder.
A nurse is observing an infant who is lying on his back.
The nurse notices that when the infant’s head is turned to the right, his right arm and leg extend, while his left arm and leg flex.
The nurse recognizes this as which of the following reflexes?
Explanation
This is a normal reflex that is present in newborns and disappears by 4 to 6 months of age.It is also known as the fencing reflex because the infant assumes a position similar to a fencer when the head is turned to one side.
A nurse is performing a neurological assessment on a 4-month-old infant.
The nurse gently drops the infant’s head backward while supporting the body.
The nurse expects to see which of the following responses as part of a normal reflex?
Explanation
This is part of theMoro reflex, also called the startle reflex, which is normally present in infants up to about 4 to 6 months old.The reflex is triggered by a loud sound, a sudden movement, or a change in temperature, and causes the baby to throw back his or her head, extend his or her arms and legs, and then pull them back in.
A nurse is performing a neurological examination on a client who has a history of multiple sclerosis.
The nurse notices that the client has difficulty walking and maintaining balance.
Which of the following tests should the nurse use to assess the client’s coordination?
Explanation
The nurse should use all of these tests to assess the client’s coordination, as they are part of a neurological exam for people with MS.
A nurse is evaluating a client who has a suspected stroke.
The nurse asks the client to stick out his tongue and observes that it deviates to the left side.
Which of the following cranial nerves is most likely affected?
Explanation
The hypoglossal nerve controls the movement of the tongue.If this nerve is damaged, the tongue will deviate to the side of the lesion when protruded.
A nurse is performing a routine check-up on a 2-month-old infant.
The nurse gently drops the infant from one hand to the other and observes that the infant’s arms and legs symmetrically extend, then abduct while fingers spread to form a C-shape.
The nurse identifies this as:
Explanation
The Moro reflex, or startle reflex, is a newborn reflex that occurs when a baby is startled by a loud noise or sudden movement.The baby responds by extending and abducting the arms and legs, spreading the fingers to form a C-shape, and then bringing the arms and legs back to the chest.This reflex is present at birth and disappears by 3 to 6 months of age.
A nurse is evaluating an infant’s neuromuscular development by testing different reflexes.
The nurse strokes the outer edge of the sole of the infant’s foot up toward the toes and observes that the infant’s toes fan upward and out.
The nurse documents this as:
Explanation
This is a newborn reflex that occurs when the infant is startled by a loud noise or a sudden movement.The infant’s arms and legs symmetrically extend, then abduct while fingers spread to form a C-shape.This reflex helps the infant cling to the mother in case of a threat.
A nurse is observing a newborn’s reactions to different stimuli.
The nurse touches the corner of the newborn’s mouth with a finger and sees that the newborn turns her head toward that side and starts to suck.
The nurse recognizes this as:
Explanation
This reflex starts when the corner of the baby’s mouth is stroked or touched.
The baby will turn his or her head and open his or her mouth to follow and root in the direction of the stroking.This helps the baby find the breast or bottle to start feeding.
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