A nurse is caring for a 2-day-old newborn who is undergoing phototherapy for treatment of hyperbilirubinemia.
Which of the following actions should the nurse take?

Choice A rationale

Tingling in the fingers, also known as carpal tunnel syndrome, is more commonly associated with the later stages of pregnancy when fluid retention is more pronounced. It is not typically a common discomfort during the first trimester.

Choice B rationale

Round ligament pain is more common in the second trimester when the uterus is growing rapidly and the ligaments supporting it stretch. This type of pain usually manifests as sharp, shooting pain in the lower abdomen or groin.

Choice C rationale

Perineal discomfort and pressure are more common in the later stages of pregnancy, particularly in the third trimester, as the baby descends into the pelvis and prepares for birth. It is not typically a discomfort experienced during the first trimester.

Choice D rationale

Increased urgency and frequency of urination are common discomforts during the first trimester of pregnancy. This occurs due to hormonal changes and the growing uterus pressing on the bladder, which reduces its capacity.

Choice A rationale

A positive Babinski reflex is characterized by the fanning out of the toes and the upward movement of the big toe when the sole of the foot is stroked. This reflex is normal in infants up to 2 years old and indicates an immature central nervous system. The presence of this reflex in older children or adults can indicate neurological issues.

Choice B rationale

Curling in of the toes when the sole of the foot is stroked is indicative of the plantar grasp reflex, not the Babinski reflex. The plantar grasp reflex is a different neurological response and does not indicate the same neurological development as the Babinski reflex.

Choice C rationale

No response when the sole of the foot is stroked could indicate a lack of neurological response or an issue with the sensory or motor pathways. This is not characteristic of a positive Babinski reflex and could be a sign of neurological impairment.

Choice D rationale

The big toe bending down when the sole of the foot is stroked is a normal response in older children and adults, known as the plantar reflex. This response indicates a mature central nervous system and is not characteristic of a positive Babinski reflex in infants.