When assessing a newborn's 5-minute Apgar score, how will the nurse determine reflex irritability?
A) Dorsiflexing a foot against pressure resistance
B) Raising the infant's head and letting it fall back
C) Tightly flexing the infant's trunk and then releasing it
D) Slapping the soles of the feet and observing the response
D
Feedback:
One of two possible cues is used to evaluate reflex irritability: response to a suction catheter in the nostrils or response to having the soles of the feet slapped. Reflex irritability is not assessed by dorsiflexing the foot, permitting the head to fall, or flexing the infant's trunk and releasing it.
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