A nurse is assessing a newborn's reflexes. The nurse strokes the lateral sole of the newborn's foot from the heel to the ball of the foot to elicit which reflex?
stepping
Babinski
tonic neck
plantar grasp
The Correct Answer is B
A. Stepping reflex is elicited by holding the newborn upright with feet touching a flat surface; the baby will make stepping movements.
B. Babinski reflex is correct. This reflex is elicited by stroking the lateral sole of the foot from the heel to the ball of the foot. A positive Babinski response in newborns is dorsiflexion of the big toe and fanning of the other toes — a normal finding up to about 12 months of age.
C. Tonic neck reflex (also called the “fencing” reflex) is seen when the newborn's head is turned to one side — the arm on that side extends while the opposite arm bends.
D. Plantar grasp is elicited by pressing a finger against the sole of the foot near the toes; the newborn will respond by curling the toes downward.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Limit the amount of time the infant nurses on each breast is not an effective strategy for preventing sore nipples. The issue is usually related to poor latch or positioning, not the duration of breastfeeding. Limiting nursing time could negatively impact milk supply and bonding.
B. Apply nipple shields when not breastfeeding the infant is not typically recommended as a preventive measure for sore nipples. Nipple shields are more often used to assist with latching problems, not to prevent soreness. Prolonged use can sometimes contribute to nipple confusion and further complications.
C. Instruct client to apply lanolin-based product to nipples can provide temporary relief for sore or cracked nipples, but it does not prevent soreness. The root cause of nipple pain is often related to improper positioning and latch, so this is more of a remedy than a preventive measure.
D. Ensure that the client positions and latches the infant correctly on the breast is the most effective way to prevent sore nipples. A proper latch ensures that the infant is effectively removing milk and reduces the likelihood of nipple trauma. The nurse should help the client with correct positioning, ensuring that the infant's mouth covers a large portion of the areola, not just the nipple.
Correct Answer is C
Explanation
A. Advanced maternal age may increase the risk of certain pregnancy complications, but it is not specifically associated with shoulder dystocia. Other factors, such as fetal size, are more directly related to shoulder dystocia.
B. Polyhydramnios (excess amniotic fluid) can sometimes be associated with complications during labor, but it is not the primary risk factor for shoulder dystocia. The condition most often involves difficulties with the fetal position or size rather than the amount of fluid.
C. Macrosomia (a large baby, typically defined as a birth weight over 8 pounds 13 ounces or 4000g) is the primary risk factor for shoulder dystocia. Shoulder dystocia occurs when the baby’s shoulders become stuck during delivery, often due to the larger size of the baby. The baby’s shoulders may be too broad to pass through the birth canal easily, which increases the likelihood of this complication.
D. Preterm birth is not a significant risk factor for shoulder dystocia. Preterm babies are typically smaller and less likely to encounter the same birth canal obstruction issues associated with shoulder dystocia.
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