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 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.
Correct Answer is A
Explanation
(A) "You should check the identity of individuals who come to remove your baby from the room":
It's crucial for parents to verify the identity of anyone who comes to take their baby out of the room. This helps ensure the baby's safety and prevents unauthorized individuals from taking the baby. Hospital staff usually wear identification badges, and parents should be encouraged to ask for and verify this identification.
(B) "We will scan your baby's identification bracelet each time check on him":
While scanning the baby's identification bracelet might be part of some hospital protocols for specific purposes like medication administration or matching mother and baby during certain procedures, it is not typically done every time a nurse checks on the baby. Continuous scanning is not a standard practice and would be logistically impractical.
(C) "We will match the bracelet on your baby with his footprint record each shift":
Matching the baby's bracelet with footprint records each shift is not a standard safety protocol. Footprints are usually taken at birth for records but are not routinely matched every shift. Identification is more reliably ensured through the use of identification bands worn by both the mother and the baby.
(D) "Your baby will wear an electronic bracelet when he is out of your room":
In many hospitals, electronic bracelets are used as a security measure, but they are typically worn by the baby at all times, not just when the baby is out of the room. This measure helps prevent abduction and ensures the baby's location is monitored continuously.
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