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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. By 12 days postpartum, the fundus should be about 2 cm below the umbilicus, as the uterus is returning to its pre-pregnancy size. This is a normal finding at this stage of postpartum recovery.
B. At 12 days postpartum, the fundus should still be palpable, though it will be much lower than in the immediate postpartum period.
C. This is too low for 12 days postpartum. The fundus should not descend this far yet.
D. Halfway below the umbilicus would be expected around 7-10 days postpartum, but by 12 days, the fundus should be about 2 cm below the umbilicus, indicating more involution.
Correct Answer is D
Explanation
A. Using a radiant warmer to transport a newborn helps prevent radiant heat loss, not convection. Radiant heat loss occurs when heat transfers from the newborn to cooler surfaces not in direct contact, such as walls or windows.
B. Placing a cap on a newborn's head is effective in reducing evaporative and radiant heat loss from the head, but it does not specifically address heat loss through air movement (convection).
C. Placing the newborn skin-to-skin with the mother reduces conductive heat loss by providing a warm surface (the mother's skin), not convection.
D. Closing doors and windows to prevent draft helps reduce convective heat loss, which occurs when air currents pass over the newborn's skin and carry away body heat. Eliminating drafts minimizes this form of heat loss, making this the correct intervention for convection.
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