Maternity Nursing Q 5
When the nurse on duty accidentally bumps the bassinet, the neonate throws out its arms, hands open, and begins to cry. The nurse interprets this reaction as indicative of which of the following reflexes?
A. Startle reflex
B. Babinski reflex
C. Grasping reflex
D. Tonic neck reflex
Correct Answer: A. Startle reflex
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.
Option B: Babinski reflex occurs after the sole of the foot has been firmly stroked. The big toe then moves upward or toward the top surface of the foot. The other toe fan out.
Option C: Palmar grasp reflex appears around 16 weeks of gestation and can be elicited in preterm infants as young as 25 weeks of postconceptional age. To elicit the reflex, the infant is laid in a symmetrical supine and the examiner strokes the palm of the infant with his or her index finger. The response to this stimulus comprises two phases: finger closing and clinging.
Option D: When a baby’s head is turned to one side, the arm on that side stretches out and the opposite arm bends up at the elbow. The tonic neck reflex lasts until the infant is about 5 to 7 months old.