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
Kale is an excellent non-dairy source of calcium. Dark leafy greens like kale are rich in calcium, with approximately 90 mg of calcium per cup when cooked. Including kale in the diet can help pregnant women meet their calcium needs, especially if they do not consume dairy products.
(B) 1 baked potato:
While potatoes are a source of several nutrients, including potassium and vitamin C, they are not significant sources of calcium. Therefore, a baked potato would not be the best recommendation for meeting calcium needs in a client who does not consume dairy products.
(C) 1 large banana:
Bananas are nutritious fruits containing potassium and vitamin C, but they are not significant sources of calcium. Therefore, while bananas are a healthy food choice during pregnancy, they would not provide sufficient calcium for someone who does not consume dairy products.
(D) 1 cup sweet white corn:
Sweet white corn is a tasty vegetable rich in vitamins and minerals, but it is not a significant source of calcium. Therefore, while it can contribute to overall nutritional intake during pregnancy, it would not be the best recommendation for meeting calcium needs in a client who does not consume dairy products.
Correct Answer is C
Explanation
(a) Serum bilirubin:
While serum bilirubin can provide useful information about liver function, it is not the most immediate concern for a client with hyperemesis gravidarum. This condition primarily involves severe nausea and vomiting, which can lead to dehydration and ketosis.
(b) Liver enzymes:
Liver enzymes can be elevated in hyperemesis gravidarum, but they are not the primary concern. The immediate priority is to assess the extent of dehydration and metabolic disturbances.
(c) Urinalysis for ketones:
This test is the priority because it helps determine the extent of dehydration and ketosis. In hyperemesis gravidarum, severe vomiting can lead to significant fluid and electrolyte imbalances and ketosis, which need to be identified and corrected promptly to prevent further complications.
(d) CBC:
A complete blood count (CBC) provides useful information about overall health and can identify anemia or infection, but it is not the priority for immediate assessment of hyperemesis gravidarum. The immediate need is to evaluate hydration status and ketosis, which is best done through urinalysis for ketones.
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