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 B

Explanation

A. Polyhydramnios refers to an excessive amount of amniotic fluid and typically presents with maternal discomfort, dyspnea, and possibly preterm labor, but not with vaginal bleeding as a primary symptom.

B. Placenta previa is the most likely diagnosis based on the assessment findings. It typically presents with painless, bright red vaginal bleeding in the second or third trimester, a soft, nontender uterus, no contractions, and a normal fetal heart rate. The bleeding may start spontaneously and often recurs. This fits the client's clinical picture precisely.

C. Placental abruption usually involves painful vaginal bleeding, a firm or tender uterus, and may be associated with uterine contractions or abnormal fetal heart rate patterns. The absence of pain and uterine tenderness in this case makes placental abruption less likely.

D. Ruptured ectopic pregnancy would not be expected at 33 weeks’ gestation. Ectopic pregnancies typically present in the first trimester and are accompanied by severe abdominal pain, vaginal bleeding, and signs of hypovolemic shock if ruptured.

A. two fingerbreadths above the umbilicus B. two fingerbreadths below the umbilicus C. four fingerbreadths below the umbilicus D. at the level of the umbilicus

Correct Answer is B

Explanation

A. Two fingerbreadths above the umbilicus would not be a normal finding 48 hours postpartum. By this time, the uterus should be well on its way to returning to its pre-pregnancy size and position, typically about 1 to 2 fingerbreadths below the umbilicus.

B. Two fingerbreadths below the umbilicus is the expected finding 48 hours postpartum. After birth, the uterus begins to shrink (involution) and descend into the pelvic cavity. By 48 hours, the fundus is usually 1–2 fingerbreadths below the umbilicus.

C. Four fingerbreadths below the umbilicus would be more typical of a finding several days later, after the process of involution continues. This could be a sign that the uterus is shrinking at the expected rate.

D. At the level of the umbilicus is typically expected within the first 24 hours after delivery, but by 48 hours postpartum, the fundus should have descended slightly below the level of the umbilicus.

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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?

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Correct Answer is B

Explanation

A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus and documents which finding as normal?

Correct Answer is B

Explanation

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