During a newborn's assessment, the nurse noticed that the newborn showed a reflex response to a sudden loss of support and felt as if he was falling. This reflex is known as:

1. A

   The Moro reflex

2. B

   The rooting reflex

3. C

   The glabellar reflex

4. D

   Babinski's reflex

Appeared in: DSSSB 6 September 2024

Explanation

• The Moro reflex, also known as the startle reflex, is an involuntary response present in newborns.
• It is triggered by a sudden stimulus, such as a loud noise or the sensation of falling or loss of support.
• The characteristic response involves the infant symmetrically extending their arms and legs, opening their hands, and then pulling their limbs back towards the body in an embrace-like motion.
• This reflex is a key indicator of a healthy, intact central nervous system at birth.
• It typically appears at birth and disappears by 3 to 6 months of age as the infant's motor control matures.

Why Other Options Were Wrong

• Option B: The rooting reflex is a feeding reflex, not a startle or postural reflex. It is triggered by a tactile stimulus to the face.
• Option C: The glabellar reflex is a protective blinking reflex triggered by a specific tactile stimulus to the forehead, not by a change in position or support.
• Option D: Babinski's reflex is a response in the feet and toes, triggered by stimulating the sole of the foot. It is unrelated to the sensation of falling.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Identification of primitive newborn reflexes based on stimulus and response to guide bedside assessment, documentation, and the next nursing action.
• Assessing primitive reflexes is a fundamental part of the newborn neurological examination, providing critical information about the infant's brain and nerve function.
• The presence, strength, and symmetry of these reflexes help determine neurological maturity and can be the first sign of an underlying neurological or musculoskeletal problem.
• What if? - If the Moro reflex were absent on one side (asymmetrical), it would be a red flag for a potential birth injury, such as a fractured clavicle or a brachial plexus injury on the non-responsive side, requiring immediate orthopedic and neurological evaluation.

How to Approach the Question

• First, carefully read the clinical scenario and identify the specific stimulus described. Here, the key phrases are 'sudden loss of support' and 'felt as if he was falling'.
• Next, recall the common primitive reflexes tested in a newborn assessment and the specific trigger for each one.
• Match the stimulus from the question to the known reflex triggers. The sensation of falling is the classic stimulus for the Moro reflex.
• Systematically evaluate each option. The rooting reflex is triggered by a cheek stroke, the glabellar reflex by a forehead tap, and Babinski's reflex by stroking the sole of the foot.
• Conclude that the Moro reflex is the only option that matches the described stimulus and response, making it the correct answer.

Concept Tested & Keywords

• Concept Tested: Identification of primitive newborn reflexes based on stimulus and response.
• Stem keywords: newborn assessment, reflex response, sudden loss of support, falling
• Lead-in keywords: known as

Question ID

Qsw8f8u3tU5l2AM2KbykMW

Copy ID

Reference Book

E6 Anatomy Grays 43e Vol 1 Part 2 p. 97-99

E6 Comprehensive Textbook of Community Health NursingShyamala D part 1 (pp 26-389 of 389) p. 301-303