RN Nursing · Newborn Assessment · Practice question
A nurse is caring for a newborn and assessing newborn reflexes. To elicit the tonic neck reflex, the nurse should take which of the following actions?
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Hold the newborn vertically allowing one foot to touch the table surface.
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✓
Turn the newborn's head quickly to one side.
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Place a finger at the base of the newborn's fingers.
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Perform a sharp hand clap near the infant.
Answer & explanation
Correct: Turn the newborn's head quickly to one side.
The tonic neck reflex, also called the fencing reflex, is elicited by quickly turning the newborn's head to one side while the infant is in a supine position. The expected response is extension of the arm and leg on the side the face is turned toward, and flexion of the opposite arm and leg — resembling a fencing posture. This reflex is normal in newborns and typically disappears by 4 to 6 months of age. Holding the newborn vertically and allowing one foot to touch a surface describes the stepping or walking reflex, not the tonic neck reflex. Placing a finger at the base of the newborn's fingers elicits the palmar grasp reflex, in which the infant's fingers curl around the examiner's finger. Performing a sharp hand clap near the infant elicits the Moro (startle) reflex, characterized by arm abduction and extension followed by adduction. Each of these reflexes has a distinct stimulus and response, and it is important for nurses to correctly distinguish them, as their presence and symmetry provide information about neurological integrity in the newborn.
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