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?
A.
Hold the newborn vertically allowing one foot to touch the table surface.
B.
Perform a sharp hand clap near the infant.
C.
Place a finger at the base of the newborn’s toes.
D.
Turn the newborn’s head quickly to one side.
The Correct Answer and Explanation is :
The correct answer is B. Perform a sharp hand clap near the infant.
Explanation:
The Moro reflex, also known as the startle reflex, is an important primitive reflex that is typically assessed in newborns to evaluate their neurological function and developmental status. This reflex is a response to a sudden noise or movement, and it helps in identifying the integrity of the central nervous system, particularly the brainstem and spinal cord.
To elicit the Moro reflex, the nurse should perform a sharp hand clap or produce a loud noise near the infant. This sudden auditory stimulus triggers a reaction from the baby. The typical response to the Moro reflex involves the following sequence:
- Startle Reaction: The infant may initially show a startled reaction by spreading out their arms and legs in response to the noise or movement.
- Abduction of Arms: The baby’s arms will typically spread out away from the body, with the fingers often splayed.
- Adduction of Arms: Following the initial abduction, the baby will then draw their arms back towards their body in a hugging motion.
- Crying: Sometimes, the infant may also cry in response to the startle.
This reflex is most pronounced in the first few months of life and usually disappears by around 4 to 6 months of age as the nervous system matures. The Moro reflex is a critical part of the newborn neurological examination and provides insight into the baby’s brain and nervous system function.
Explanation of Other Options:
- A. Hold the newborn vertically allowing one foot to touch the table surface: This action is used to assess the stepping reflex, not the Moro reflex. The stepping reflex involves the baby making stepping movements when their foot touches a surface.
- C. Place a finger at the base of the newborn’s toes: This action tests the plantar grasp reflex, where the baby will curl their toes around the object.
- D. Turn the newborn’s head quickly to one side: This action would be used to assess the asymmetric tonic neck reflex (ATNR), where the baby’s arm and leg on the side to which the head is turned extend while the opposite side flexes.
In summary, the correct method to elicit the Moro reflex involves creating a sudden noise near the newborn, which is effectively done by performing a sharp hand clap.