QUESTION: "When the nurse accidentally bumps the bassinet, the neonate throws out its arms, hands opened, and begins to cry. The nurse interprets this reaction as indicative of which of the following reflexes? "
CHOICES
( O ) a.) Startle reflex.
( X ) b.) Babinski reflex.
( X ) c.) Grasping reflex.
( X ) d.) Tonic neck reflex.
RATIONALE: The Moro, or startle, reflex occurs when the neonate responds to stimuli by extending the arms, hands open, and then moving the arms in an embracing motion. The Moro reflex, present at birth, disappears at about age 3 months. The Babinski reflex is elicited by stroking the neonate's foot resulting in the fanning of the toes. This reflex is normal in the neonate until approximately 3 months of age. The grasping reflex is demonstrated when the neonate grasps an object placed in the hand. The tonic neck reflex (or fencing reflex) is demonstrated when the neonate, lying supine, turns the head to one side. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
