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. Plantar grasp reflex D. Stepping reflex

Correct Answer is A

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.

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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

Correct Answer is A

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:

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 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 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 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 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?

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 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.)