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 D

Explanation

Choice D rationale

The normal respiratory rate for a newborn is between 30 to 60 breaths per minute. A rate of 60/min is within this range.

Choice A rationale

A respiratory rate of 110/min is too high for a newborn and may indicate respiratory distress.

Choice B rationale

A respiratory rate of 100/min is also too high for a newborn and may indicate respiratory distress.

Choice C rationale

A respiratory rate of 24/min is too low for a newborn and may indicate respiratory depression.

A. The infant stretches their arms out and then back in toward their body. B. The infant turns their head toward their parent’s voice. C. The infant grasps the parent’s finger when placed in the infant’s palm. D. The infant brings their hand to their mouth.

Correct Answer is D

Explanation

Choice A rationale

Stretching arms out and then back in is a common reflex in newborns known as the Moro reflex. It is not a sign of feeding readiness but rather a response to a sudden loss of support or a loud noise.

Choice B rationale

Turning the head toward a parent’s voice is a sign of auditory recognition and bonding, not necessarily feeding readiness. It indicates the infant’s ability to recognize familiar sounds.

Choice C rationale

Grasping a parent’s finger when placed in the infant’s palm is a primitive reflex known as the palmar grasp reflex. It is not related to feeding readiness but is a normal reflexive action in newborns.

Choice D rationale

Bringing their hand to their mouth is a sign of feeding readiness. This action indicates that the infant is hungry and ready to feed. It is an early cue that the baby is ready to eat.

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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 and assessing newborn reflexes.
To elicit the Babinski reflex, the nurse should take which of the following actions?