A nurse is performing an assessment of a newborn’s Babinski reflex. Which of the following findings should the nurse expect?
Eversion of the great toe
Flexion of the forearm
Downward curl of the toes
Extension of the leg
The Correct Answer is A
The Babinski reflex is a normal reflex present in newborns and infants up to about 2 years old. It is elicited by stroking the lateral aspect of the sole of the foot from the heel towards the toes. A positive Babinski reflex is characterized by dorsiflexion (upward movement) of the big toe and fanning out of the other toes. This is also known as an extensor response.
Therefore, option a, eversion of the great toe, is the expected finding for a positive Babinski reflex. Options b, c, and d are not consistent with a positive Babinski reflex.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale for A: Monitoring the rectal temperature is important, but every 4 hours may not be frequent enough to assess for signs of infection or other complications in a newborn with myelomeningocele.
Rationale for B: Administering broad-spectrum antibiotics is crucial to prevent infection, especially in cases of myelomeningocele where the protective covering of the spinal cord is compromised.
Rationale for C: Cleansing the site with povidone-iodine is not recommended as it can be irritating and potentially harmful to the delicate tissue surrounding the defect.
Rationale for D: Surgical closure is typically performed as soon as possible after birth, often within 24 hours, rather than delaying it for 72 hours.
Correct Answer is D
Explanation
New onset tachypnea in a newborn is a concerning symptom and requires immediate assessment by the nurse. Tachypnea is defined as a respiratory rate greater than 60 breaths per minute in a newborn. It can be a sign of respiratory distress or other serious conditions, such as sepsis or cardiac disease.
Option a. A newborn who has a short frenulum and is having difficulty breastfeeding is a common issue that can be addressed by the nurse or lactation consultant. It does not require immediate assessment.
Option b. A newborn who is 24 hr old and has not had a meconium stool may be concerning, but it is not an emergency situation. It may be a sign of a bowel obstruction, but it is not an urgent condition.
Option c. A newborn who is 10 hr old and has blood-tinged discharge in her diaper may be a concerning symptom, but it is not an emergency situation. It may be related to maternal hormones and is a common finding in newborns.
Therefore, the correct option is d. A newborn who is 10 hr old and has new onset tachypnea. The nurse should assess the newborn's respiratory status, heart rate, and oxygen saturation and notify the healthcare provider immediately if there are any concerns.
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