A nurse is checking the reflexes of a newborn. Which of the following actions should the nurse use to elicit the Babinski reflex?

Touch the corner of the newborn's mouth.

Place the newborn supine and apply pressure to the soles of the feet.

Stroke upward on the lateral aspect of the sole of the newborn's foot

Pull the newborn up by the wrist from a supine position.

Answer and Explanation

The Correct Answer is C

(a) Touch the corner of the newborn's mouth:
Touching the corner of the newborn's mouth elicits the rooting reflex, not the Babinski reflex. The rooting reflex causes the newborn to turn their head toward the touch and open their mouth, which helps with feeding.

(b) Place the newborn supine and apply pressure to the soles of the feet:
Applying pressure to the soles of the feet is not a method used to elicit the Babinski reflex. This action might influence other reflexes but not the Babinski.

(c) Stroke upward on the lateral aspect of the sole of the newborn's foot:
This is correct. The Babinski reflex is elicited by stroking upward on the lateral aspect of the sole of the newborn's foot. A positive response is the fanning and extension of the toes, which is normal in newborns.

(d) Pull the newborn up by the wrist from a supine position:
Pulling the newborn up by the wrists from a supine position is used to assess the traction response or pull-to-sit maneuver, which tests the newborn's head control and muscle tone, not the Babinski reflex.

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Correct Answer is B

Explanation

Answer: B. Determine the newborn's respiratory rate.

Rationale:

A. Weigh the newborn's wet diaper:
While monitoring fluid output is important in assessing hydration status and overall health, it is not the immediate priority. In the context of a newborn with neonatal abstinence syndrome (NAS), the respiratory status takes precedence, especially given that withdrawal can affect respiratory function.

B. Determine the newborn's respiratory rate:
Assessing the respiratory rate is crucial, as newborns with NAS may experience respiratory distress, including increased respiratory effort or apnea. Identifying any respiratory issues early allows for prompt intervention, which is vital for the newborn's safety and well-being. Ensuring adequate respiratory function is a priority in this population.

C. Auscultate the newborn's bowel sounds:
While assessing bowel sounds is relevant to monitoring gastrointestinal function and potential withdrawal symptoms, it is not the immediate priority. Changes in bowel sounds may occur due to the syndrome, but respiratory assessment should come first to ensure stability.

D. Swaddle the newborn in blankets:
Swaddling can provide comfort to a newborn with NAS; however, it is not the first action to take. Comfort measures are important, but they should follow critical assessments of the newborn's respiratory and overall clinical status to ensure safety.

A. Urination urgency and frequency B. Tingling in the fingers C. Round ligament pain D. Perineal discomfort and pressure

Correct Answer is A

Explanation

(A) Urination urgency and frequency:
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.

(B) Tingling in the fingers:
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.

(C) Round ligament pain:
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.

(D) Perineal discomfort and pressure:
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.

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A nurse is checking the reflexes of a newborn. Which of the following actions should the nurse use to elicit the Babinski reflex?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

Rationale:

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Correct Answer is A

Explanation

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