A nurse is collecting data from a newborn.
The nurse should recognize that which of the following images demonstrates a positive Babinski reflex?
Image of a newborn with toes fanning out when the sole of the foot is stroked.
Image of a newborn with toes curling in when the sole of the foot is stroked.
Image of a newborn with no response when the sole of the foot is stroked.
Image of a newborn with the big toe bending down when the sole of the foot is stroked.
The Correct Answer is A
Choice A rationale
A positive Babinski reflex is characterized by the fanning out of the toes and the upward movement of the big toe when the sole of the foot is stroked. This reflex is normal in infants up to 2 years old and indicates an immature central nervous system. The presence of this reflex in older children or adults can indicate neurological issues.
Choice B rationale
Curling in of the toes when the sole of the foot is stroked is indicative of the plantar grasp reflex, not the Babinski reflex. The plantar grasp reflex is a different neurological response and does not indicate the same neurological development as the Babinski reflex.
Choice C rationale
No response when the sole of the foot is stroked could indicate a lack of neurological response or an issue with the sensory or motor pathways. This is not characteristic of a positive Babinski reflex and could be a sign of neurological impairment.
Choice D rationale
The big toe bending down when the sole of the foot is stroked is a normal response in older children and adults, known as the plantar reflex. This response indicates a mature central nervous system and is not characteristic of a positive Babinski reflex in infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Based on the provided information, here’s the completed diagram:
Potential Condition
- D. Endometritis
Actions to Take
- A. Administer broad-spectrum antibiotics
- D. Administer analgesics
Parameters to Monitor
- A. Lochia amount and odor
- B. Temperature
Explanation of Other Conditions
- Deep vein thrombosis (DVT):
- Reasoning: The client has bilateral edema without pain, warmth, or tenderness, which are typical signs of DVT. Additionally, the primary symptoms (malaise, chills, fever, foul-smelling lochia) are more indicative of an infection like endometritis.
- Urinary tract infection (UTI):
- Reasoning: The client is voiding frequently without difficulty, and there are no specific urinary symptoms like dysuria or urgency. The presence of foul-smelling lochia and a boggy, tender uterus points more towards endometritis.
- Engorgement:
- Reasoning: While the client’s breasts are firm and heavy, she denies nipple discomfort, and the primary symptoms (fever, chills, malaise, foul-smelling lochia) are more consistent with an infection rather than simple breast engorgement.
Correct Answer is A
Explanation
Choice A rationale
A positive Babinski reflex is characterized by the fanning out of the toes and the upward movement of the big toe when the sole of the foot is stroked. This reflex is normal in infants up to 2 years old and indicates an immature central nervous system. The presence of this reflex in older children or adults can indicate neurological issues.
Choice B rationale
Curling in of the toes when the sole of the foot is stroked is indicative of the plantar grasp reflex, not the Babinski reflex. The plantar grasp reflex is a different neurological response and does not indicate the same neurological development as the Babinski reflex.
Choice C rationale
No response when the sole of the foot is stroked could indicate a lack of neurological response or an issue with the sensory or motor pathways. This is not characteristic of a positive Babinski reflex and could be a sign of neurological impairment.
Choice D rationale
The big toe bending down when the sole of the foot is stroked is a normal response in older children and adults, known as the plantar reflex. This response indicates a mature central nervous system and is not characteristic of a positive Babinski reflex in infants.
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