A nurse is checking the reflexes of a newborn.
Which of the following actions should the nurse use to elicit the Babinski reflex?
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.
Touch the corner of the newborn’s mouth.
The Correct Answer is B
Choice A rationale
Placing the newborn supine and applying pressure to the soles of the feet is not the correct method to elicit the Babinski reflex. This action does not stimulate the appropriate nerve pathways involved in the reflex.
Choice B rationale
Stroking upward on the lateral aspect of the sole of the newborn’s foot is the correct method to elicit the Babinski reflex. This action stimulates the plantar reflex, causing the big toe to extend upward and the other toes to fan out.
Choice C rationale
Pulling the newborn up by the wrist from a supine position is used to elicit the traction response, not the Babinski reflex. The traction response involves the newborn flexing their arms and attempting to lift their head.
Choice D rationale
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 stimulus and open their mouth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Based on the provided information,
Most Likely Potential Condition
- A. Placenta previa
Actions to Take
- A. Reinforce with the client to maintain bed rest
- C. Insert a large bore intravenous catheter
Parameters to Monitor
- B. Fetal well-being
- D. Vaginal bleeding
Explanation of Other Conditions
- Abruptio placentae:
- Reasoning: This condition typically presents with painful bleeding and a tender, rigid abdomen, which is not consistent with the client’s symptoms of painless, bright red bleeding and a soft, non-tender abdomen.
- Preterm labor:
- Reasoning: The client shows no signs of labor, such as uterine contractions or cervical dilation. The bleeding is also bright red and painless, which is more indicative of placenta previa.
- Cervical insufficiency:
- Reasoning: This condition usually involves painless cervical dilation and effacement without contractions, leading to preterm birth. The client’s cervix is not dilated, and there are no signs of labor, making this condition less likely.
Correct Answer is D
Explanation
Choice A rationale
Providing additional hydration by offering glucose water is not recommended. Breast milk or formula should be the primary source of hydration for newborns.
Choice B rationale
Monitoring the newborn’s heart rate every 2 hours is not necessary for phototherapy. The focus should be on monitoring bilirubin levels, hydration status, and ensuring the newborn’s eyes are protected.
Choice C rationale
Applying a water-based lotion to the newborn’s skin every 4 hours is not recommended. Lotions can interfere with the effectiveness of phototherapy and may cause skin irritation.
Choice D rationale
Removing the newborn from phototherapy every 2 hours for breastfeeding is recommended. Frequent breastfeeding helps to promote bilirubin excretion and maintain hydration.
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