The nurse attempts to elicit the Moro reflex on a newborn and assesses movement of the right arm only. Based on this finding, the nurse immediately assesses the:

Question

1. Ortolani maneuver.
2. Babinski reflex.
3. Clavicle.
4. Gallant reflex.

Answer 1

3
Rationale 1: Ortolani maneuver is an assessment technique that rules out the possibility of congenital hip dysplasia.
Rationale 2: Babinski reflex tests for upper neuron abnormalities.
Rationale 3: 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.
Rationale 4: Trunk incurvation (Gallant reflex) is seen when the newborn is prone and the pelvis is turned to the stimulated side when the spine is stroked.