A nurse is caring for a newborn and assessing newborn reflexes.
To elicit the Babinski reflex, the nurse should take which of the following actions?

Tickle the outer edge of the sole of the newborn’s foot moving up toward the toes.

Turn the newborn’s head quickly to one side.

Hold the newborn vertically allowing one foot to touch the table surface.

Clap near the crib and make a loud noise.

Answer and Explanation

The Correct Answer is A

Choice A rationale

The Babinski reflex is elicited by stroking the outer edge of the sole of the newborn’s foot, moving up toward the toes. This causes the big toe to move upward and the other toes to fan out.

Choice B rationale

Turning the newborn’s head quickly to one side is used to elicit the tonic neck reflex, not the Babinski reflex.

Choice C rationale

Holding the newborn vertically and allowing one foot to touch the table surface is used to elicit the stepping reflex, not the Babinski reflex.

Choice D rationale

Clapping near the crib and making a loud noise is used to elicit the startle (Moro) reflex, not the Babinski reflex.

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Correct Answer is B

Explanation

Choice A rationale

Erythema toxicum is a common, benign rash in newborns but does not cause swelling that crosses suture lines.

Choice B rationale

A caput succedaneum is swelling of the scalp that crosses suture lines and is caused by prolonged pressure on the head during delivery.

Choice C rationale

Mongolian spots are benign, flat, congenital birthmarks with wavy borders and irregular shapes, typically found on the lower back and buttocks, not the head.

Choice D rationale

A cephalhematoma is a collection of blood between the skull bone and its periosteum that does not cross suture lines. .

A. Small for gestational age (SGA). B. Appropriate (average) for gestational age (AGA). C. Low birth weight. D. Large for gestational age (LGA).

Correct Answer is B

Explanation

Choice A rationale

Small for gestational age (SGA) refers to newborns whose birth weight is below the 10th percentile for their gestational age.

Choice B rationale

Appropriate for gestational age (AGA) refers to newborns whose birth weight is between the 10th and 90th percentiles for their gestational age. A newborn weighing 3350 g at 39 weeks gestation falls within this range.

Choice C rationale

Low birth weight is defined as a birth weight of less than 2500 g, which does not apply to this newborn.

Choice D rationale

Large for gestational age (LGA) refers to newborns whose birth weight is above the 90th percentile for their gestational age.

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A nurse is caring for a newborn and assessing newborn reflexes.To elicit the Babinski reflex, the nurse should take which of the following actions?

Nursing Test Bank

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A nurse is caring for a newborn delivered by vaginal birth after 3 hours of pushing.The newborn’s mother asks about the swollen area on her son’s head.After palpation and identification that the swelling does cross the suture line, which of the following is an appropriate response by the nurse?

Correct Answer is B

Explanation

A nurse is caring for a newborn who was born at 39 weeks gestation and weighs 3350 g. Based on the weight and gestational age, what is the most appropriate way to document the findings?

Correct Answer is B

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A nurse is caring for a newborn and assessing newborn reflexes.
To elicit the Babinski reflex, the nurse should take which of the following actions?