While eliciting the Moro reflex in a newborn, the nurse notes that only the right arm moves. What should the nurse immediately assess based upon this finding?
1. The clavicle
2. Babinski reflex
3. The rooting reflex
4. Ortolani maneuver
1
Explanation:
1. When the Moro reflex is elicited, the newborn will straighten both arms and hands outward while the knees are flexed, then slowly return the arms to the chest, as in an embrace. If this response is not elicited, the nurse will assess the clavicle. If the clavicle is fractured, the response will be demonstrated on the unaffected side only.
2. The Babinski reflex tests for upper neuron abnormalities.
3. The rooting reflex is elicited when the side of the newborn's mouth or cheek is touched. In response, the newborn turns toward that side and opens the lips to suck (if not fed recently).
4. The Ortolani maneuver is an assessment technique that rules out the possibility of congenital hip dysplasia.
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