A nurse is assessing a 3-day-old newborn. Which finding would indicate a normal primitive reflex?
The nurse observes the newborn's reflexes during a routine assessment.
1When the nurse strokes the sole of the foot from heel to toe, the toes fan out and the big toe extends upward.✓ 정답
2When the nurse claps hands loudly near the newborn, the infant extends arms and legs then brings them back to midline.
3When the nurse places a finger in the newborn's palm, the infant grasps the finger tightly.
4When the nurse turns the newborn's head to one side, the arm and leg on that side extend while the opposite limbs flex.
해설
The Babinski reflex (toes fan out and big toe extends when sole is stroked) is normal in newborns. Other options describe Moro (2), grasp (3), and tonic neck (4) reflexes.
Core Nursing ExplanationKey Concept Analysis: This question assesses knowledge of Primitive (Neonatal) Reflexes. These are involuntary, automatic responses present at birth that indicate normal neurological development. They typically disappear within the first few months to a year as higher brain centers mature and voluntary control develops. The key is to identify which described finding is a normal reflex for a newborn.
Answer Rationale: Key Point! The correct answer is option 1, which describes the Babinski reflex (Plantar reflex). In infants, the normal response is dorsiflexion of the big toe and fanning of the other toes when the lateral sole is stroked from heel to toe. This is a normal finding in newborns and infants up to about 12-24 months of age. Its presence in an adult is abnormal and indicates possible upper motor neuron (UMN) lesion.
Distractor Analysis:
Watch out for confusion! Option 2 describes the Moro (Startle) reflex. The normal response is a symmetrical "embracing" motion: sudden extension and abduction of the arms and legs, followed by flexion and adduction (bringing them back to midline). While this is a normal primitive reflex, the description in the option is slightly incomplete but generally correct. However, it is not the finding the question is asking for as the indicator of a normal primitive reflex in this context, as the Babinski is the classic example of a reflex that is normal in infants but pathological in adults.
Option 3 describes the Palmar grasp reflex. This is normal, but again, not the specific reflex indicated by the question.
Option 4 describes the Asymmetric Tonic Neck Reflex (ATNR) or "fencing posture". This is also a normal primitive reflex. The key distinction for this question is that the Babinski reflex has a unique characteristic of being normal only in infancy.
Related Concepts: Assessment of primitive reflexes is a crucial part of the Newborn Neurological Assessment. Their absence, asymmetry, or persistence beyond the expected age can signal neurological problems such as cerebral palsy, brachial plexus injury, or developmental delays. The nursing role involves accurate assessment, documentation, and reporting of abnormal findings.Nursing Clinical Practice GuideClinical Scenario: You are a nurse in the well-baby nursery. During a shift assessment on a 36-hour-old term newborn, you perform a neurological screening as part of the routine exam.
Nursing Intervention Strategy:
Assessment: Ensure the infant is in a quiet, alert state. Perform reflexes systematically:
Babinski: Use your thumb to firmly stroke the lateral aspect of the sole from heel to toe. Observe for toe fanning and big toe extension.
Moro: Gently support the infant's head and shoulders, then allow the head to drop back slightly (simulating a sensation of falling). Observe for symmetrical arm extension/abduction followed by flexion.
Rooting & Sucking: Stroke the cheek; the infant should turn toward the stimulus and open mouth. Place a gloved finger in the mouth to assess suck.
Palmar & Plantar Grasp: Place a finger in the palm or against the ball of the foot; the infant should curl fingers/toes tightly.
Nursing Care: Document all reflexes as "present and symmetric" or note any abnormalities (e.g., "Moro reflex absent on left side"). A weak or absent reflex may indicate fatigue, so re-assess after the infant rests. Always handle the newborn gently and support the head during reflex testing.
Patient Safety and Precautions: Never perform the Moro reflex by making a loud noise, as this can be overly startling. The correct method is the "head drop" technique. Always ensure the infant is on a secure, padded surface. Report immediately: absent reflexes, markedly asymmetric responses, or hypertonia/hypotonia.
Nursing Procedure & Medication Flow
While not a medication procedure, reflex assessment is a standardized skill. The flow is: Prepare (quiet environment, warm hands) → Position infant supine on flat surface → Perform one reflex at a time → Observe and document response immediately → Comfort infant as needed.
A Word from Your Senior Nurse
"Newborn assessment is where your detective skills shine! Those little reflexes are windows into the baby's nervous system. Remember, a sleepy baby might have dampened reflexes, so timing is everything. On the NCLEX, they love to test the difference between normal infant findings and abnormal adult findings—the Babinski is the superstar of that concept. In real life, catching an absent or asymmetric Moro reflex early can be the first clue to a brachial plexus injury from a difficult delivery. Your careful assessment truly matters!"
Primitive Reflexes — Involuntary, stereotyped movements present at birth that originate in the brainstem, indicating intact lower neurological pathways. They disappear as the cerebral cortex matures.
Babinski Reflex (Plantar Reflex) — Stroking the lateral sole from heel to toe causes dorsiflexion of the big toe and fanning of the other toes. Normal in infants; indicates an upper motor neuron lesion if present in adults.
Moro Reflex (Startle Reflex) — A response to a sensation of falling: infant extends arms and legs, then flexes and adducts them in an embracing motion. Asymmetry may indicate neurological injury (e.g., clavicle fracture, brachial plexus palsy).
Asymmetric Tonic Neck Reflex — "Fencing posture": when the head is turned to one side, the arm and leg on that side extend, and the opposite limbs flex. Persistence beyond 6 months may interfere with rolling over and hand-eye coordination.
Palmar Grasp Reflex — Stroking the palm causes the infant to flex fingers in a tight grasp. This reflex is strong enough that the infant can be momentarily lifted. It typically disappears by 2-3 months.