Difficulty: Medium
Average Score: 76%
Simulated
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?
Correct answer
D
Rationale
The Moro reflex is a startle reflex observed in newborns. To elicit this reflex, a sudden loud noise or movement is needed. Performing a sharp hand clap near the infant is the appropriate action to trigger the Moro reflex. This action mimics a sudden loud noise, causing the baby to extend the arms and legs, then bring them back in a hugging motion. Placing a finger at the base of the newborn's toes (Choice A) does not elicit the Moro reflex. Turning the newborn's head quickly to one side (Choice B) triggers the asymmetric tonic neck reflex, not the Moro reflex. Holding the newborn vertically allowing one foot to touch the table surface (Choice C) elicits the stepping reflex, not the Moro reflex.