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?

The infant’s arms and legs flex and then extend

The infant’s toes curl downward when the sole of the foot is touched

The infant’s arms abduct at the elbows and the fingers spread to form a C shape

The infant makes stepping movements when held upright with feet touching a flat surface

Answer and Explanation

The Correct Answer is C

This is part of the Moro 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.

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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.

A. “The Moro reflex is also called the startle reflex because it occurs when the baby is startled by something.” B. “The Moro reflex helps the baby develop their sense of balance and coordination.” C. “The Moro reflex involves extending and flexing the arms and legs in response to a sudden movement.” D. “The Moro reflex can be used to assess the integrity of the baby’s nervous system.” E. “The Moro reflex can be triggered by changing the baby’s position or temperature.”

Correct Answer is ["A","C","D"]

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.

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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?

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Naxlex Comprehensive Predictor Exams

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 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.)

Correct Answer is ["A","C","D"]

Explanation

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:

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?

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?

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 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 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 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?