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. Have her blood checked every month for the next 360 days is correct. After a molar pregnancy (also known as a hydatidiform mole), the client must have serial monitoring of hCG levels (usually monthly for 6 to 12 months) to ensure that all molar tissue has been removed and that gestational trophoblastic disease (such as choriocarcinoma) does not develop. A rising or persistently elevated hCG level can indicate malignancy.
B. Receive Rhogam with the next pregnancy may be necessary if the client is Rh-negative, but it is not specific or essential to the follow-up care for a molar pregnancy itself.
C. Seek genetic counselling with her partner before the next pregnancy is not routinely required after a molar pregnancy unless there’s a history of recurrent molar pregnancies or other genetic concerns.
D. Becoming pregnant within the year is discouraged. Pregnancy should be avoided for at least 6 to 12 months after molar pregnancy to allow for monitoring of hCG levels without interference from a new pregnancy, which could complicate interpretation of results.
Correct Answer is A
Explanation
A. Elevated liver enzymes is a key indicator of HELLP syndrome, which stands for Hemolysis, Elevated Liver enzymes, and Low Platelets. HELLP syndrome is a severe form of preeclampsia and can lead to liver damage. Elevated liver enzymes, such as AST and ALT, are a hallmark of this condition, indicating liver dysfunction.
B. Elevated platelet count would be the opposite of what is expected in HELLP syndrome. In HELLP syndrome, there is typically low platelet count (thrombocytopenia), not an elevated one.
C. Leukocytosis refers to an increased white blood cell count, which can be indicative of an infection or inflammation, but it is not a hallmark of HELLP syndrome. HELLP syndrome primarily involves hemolysis, liver enzyme elevation, and low platelets.
D. Hyperglycemia is not a characteristic finding of HELLP syndrome. While it can occur in some pregnancy-related conditions, it is not specifically associated with HELLP syndrome. This condition is more associated with elevated liver enzymes and low platelets.
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