Practice Quiz

NCLEX-PN

Category - Health Promotion

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The nurse is assessing an 8-month-old baby girl. The following findings on assessment should alert the nurse for further evaluation except:
  1. The infant tightly grasps an object placed on her hand by closing her fingers on it
  2. When an object touches the sole of the infant, the toes grasp the object
  3. When the infant lies on her back, the arm and the leg on the side to which the head is turned extend, and the opposite arm and leg flex
  4. After hearing a loud noise, the infant abducts and extends her arms and legs and then brings her arms into an embrace position
Explanation
Answer: B - Toes grasping the object that touched the sole, or the plantar grasp reflex, disappears at about 8 to 9 months, so this finding should not alert the nurse to refer the child for further evaluation. Option A characterizes the palmar grasp reflex, which usually disappears between 5 months and 6 months. Option C refers to the tonic neck reflex, which disappears between 2 and 3 months. Option D refers to Moro reflex, which usually fades by the fourth or fifth month. These findings should alert the nurse for further evaluation.
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