HESI (Health and Environmental Sciences Institute) Health Assessment Practice Test

When should the nurse elicit the Moro reflex during an infant examination?

1. When the infant is sleeping.

2. At the end of the examination.

3. Before auscultation of the thorax.

4. Halfway through the examination.

The correct answer is: At the end of the examination.

Eliciting the Moro reflex, which is a startle reflex seen in infants, is best performed at the end of the examination. By doing this last, the nurse can ensure that the infant is calm and relaxed during most of the examination, reducing the chance of an exaggerated response to the reflex test due to anxiety or overstimulation. This timing allows the infant to be in a more natural state before eliciting a response that may cause startle or distress. Conducting the reflex test after completing most of the examination can lead to more accurate observations of the reflex's presence or absence. Performing this reflex assessment at other times, such as when the infant is sleeping or midway through the examination, could yield unreliable results since an infant may not respond appropriately if startled while in a deep sleep or if they are still fussy or unsettled during the examination. Therefore, concluding the exam with the Moro reflex gives the most accurate representation of the reflex's status.