The nurse is preparing to assess a newborn's neurological status. Which finding would require an immediate intervention?

Question

1. At rest, the infant has partially flexed arms and the legs drawn up to the abdomen.
2. When the corner of the mouth is touched, the infant turns the head that direction.
3. The infant blinks when the exam light is turned on over the face and body.
4. The right arm is flaccid while the infant brings the left arm and fist upward to the head.

Answer 1

4
Rationale 1: This is the normal resting posture of the infant.
Rationale 2: This is the rooting reflex, a normal finding in a newborn.
Rationale 3: Blinking in response to bright lights is an expected finding.
Rationale 4: Asymmetrical movement is not an expected finding, and could indicate neurological abnormality. This should be reported to the physician immediately.