While assessing a 7-month-old infant, the nurse makes a loud noise and notices the following response: abduction and flexion of the arms and legs; fanning of the fingers, and curling of the index finger and thumb in a C position,
followed by the infant bringing in the arms and legs to the body. What does the nurse know about this response?
a.
This response could indicate brachial nerve palsy.
b.
This reaction is an expected startle response at this age.
c.
This reflex should have disappeared between 1 and 4 months of age.
d.
This response is normal as long as the movements are bilaterally symmetric.
ANS: C
The Moro reflex is present at birth and usually disappears at 1 to 4 months. Absence of the Moro reflex in the newborn or its persistence after 5 months of age indicates severe central nervous system injury. The other responses are incorrect.
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