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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
(a) "You will not be able to eat or drink anything for 8 hours prior to the test."
There are no fasting requirements for a nonstress test. The client can eat and drink normally before the test. Nonstress tests do not require the same preparation as some other medical tests, such as fasting or dietary restrictions.
(b) "You will be required to lie flat on your back for the duration of the test."
Lying flat on the back can cause supine hypotension syndrome in pregnant women, which can lead to decreased blood flow to the fetus. Instead, clients are typically positioned in a semi-Fowler's or lateral position to avoid this issue.
(c) "You will receive medication through an IV line to stimulate contractions."
This describes a contraction stress test, not a nonstress test. A nonstress test involves monitoring the fetal heart rate in response to natural fetal movements without inducing contractions through medication.
(d) "You will press the provided button when you feel the baby moving during the test."
During a nonstress test, the client is instructed to press a button whenever they feel fetal movement. This helps the healthcare provider correlate fetal movements with changes in the fetal heart rate, which can indicate fetal well-being.
Correct Answer is A
Explanation
(A) Perform unbiased teaching:
The nurse should provide comprehensive and unbiased information about the various methods of contraception available. This involves explaining the pros and cons of each method, effectiveness, potential side effects, and how each method aligns with the client's lifestyle and health needs, allowing the client to make an informed decision.
(B) Assess the client's socioeconomic status:
While understanding the client's socioeconomic status can provide context for their healthcare needs and potential barriers to accessing certain types of contraception, it is not the primary action when inquiring about contraception methods. The focus should be on providing unbiased information first.
(C) Collect a dietary history:
Collecting a dietary history is not directly relevant to discussing contraception methods. While nutritional status is important for overall health, it does not significantly impact the choice of contraception.
(D) Select the best method of contraception for the client:
The nurse should not select the contraception method for the client. Instead, the nurse's role is to provide the necessary information and support for the client to make their own informed choice. Autonomy and personal preference are key factors in selecting a contraception method.
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