A newborn's Moro reflex is observed when a door slams. Which action should the nurse take?

• A. Administer sedatives.
• B. Document this behavior in the chart as a normal Moro reflex.
• C. Call the physician immediately.
• D. Place the infant in a supine position.

Answer: (B)

A Moro reflex is a normal primitive response in newborns that is triggered by a sudden stimulus, like a door slamming. When startled, the infant typically extends the arms outward, spreads the fingers, then quickly draws the arms back in toward the chest. This reaction is expected and should disappear by about 4 to 6 months of age, signaling typical neurologic development.

Documenting this observation as a normal Moro reflex in the chart is the appropriate action because it confirms normal neurobehavioral status for a newborn. There’s no need for intervention or medication for a normal reflex. Medications are inappropriate here, and calling the physician isn’t required unless the reflex is absent, asymmetrical, or abnormal in some way. While keeping the infant in a safe, supine position is important for overall safety, it doesn’t address the specific observation; the key point is recognizing and documenting the reflex as a typical finding.