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

Answer and Explanation

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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Correct Answer is C

Explanation

A. Oligohydramnios is more commonly associated with conditions like fetal growth restriction or placental insufficiency, and it is less common in twin pregnancies, which are actually more prone to polyhydramnios, especially in cases of twin-to-twin transfusion syndrome.

B. Chorioamnionitis is an infection of the fetal membranes, which can occur in any pregnancy, particularly with prolonged rupture of membranes, but it is not uniquely or especially linked to twin pregnancies.

C. Preeclampsia is correct. Women carrying twins (or other multiples) are at significantly higher risk for developing preeclampsia due to the increased placental mass and associated vascular demands. Nurses should be particularly vigilant in monitoring for signs like elevated blood pressure, proteinuria, edema, and headaches in these clients.

D. Post-term labor is less likely in twin pregnancies, as multiples are more often born preterm, not post-term, due to uterine overdistension and other complications.

A. short duration of labor B. use of anesthetics C. early ambulation D. breastfeeding

Correct Answer is B

Explanation

A. Short duration of labor is not typically associated with subinvolution. In fact, prolonged labor (not short) can be a risk factor due to increased uterine fatigue.

B. Use of anesthetics is correct. The use of certain anesthetics during labor, especially those that affect uterine tone (like general anesthesia or high doses of regional anesthesia), can contribute to uterine atony, which may lead to subinvolution—a condition where the uterus does not return to its normal size after childbirth.

C. Early ambulation actually promotes uterine involution and prevents complications like thrombophlebitis, making it a protective factor, not a contributing one.

D. Breastfeeding stimulates the release of oxytocin, which causes uterine contractions and promotes involution, making it a helpful factor in preventing subinvolution.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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