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.)

Clap hands loudly near the infant’s head

Hold the infant in a semi-sitting position and let the head drop back slightly

Stroke the edge of the infant’s mouth with a finger

Turn the infant’s head to one side while lying supine

Place an object in the infant’s palm and then remove it

Answer and Explanation

Correct Answer : B

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

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Correct Answer is C

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. Moro reflex B. Rooting reflex C. Galant’s response D. Positive support reflex

Correct Answer is A

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.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

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:

Correct Answer is A

Explanation

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?

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.)

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.)

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?

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?

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.)

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:

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.)