The nurse examines the newborn's tonic neck reflex, turning the head to the right side while lying supine, and determines that the reflex is intact when the infant:
1. Flexes the left arm and leg.
2. Makes a stepping motion with the feet.
3. Curls the toes as if trying to grasp with the feet.
4. Begins a sucking motion.
1
Rationale: The tonic neck reflex is demonstrated when the infant is supine and the head is turned to one side causing the leg and arm on the opposite side to flex.
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