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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Hypovolemic shock occurs when there is a significant decrease in the circulating blood volume, which can happen after severe bleeding during childbirth. The body tries to compensate for this decrease in blood volume by constricting blood vessels and increasing heart rate. However, these compensatory mechanisms can only last for a certain amount of time before the body starts to show signs of shock.

One of the hallmark signs of hypovolemic shock is cool, clammy skin, which is caused by the body diverting blood ﬂow away from the skin to maintain perfusion to vital organs. Other common signs and symptoms include tachycardia (fast heart rate), hypotension (low blood pressure), tachypnea (fast breathing rate), decreased urine output, and altered mental status.

A. Decrease in frequency of contractions B. BP 150/100 mm Hg C. Absent deep tendon reﬂexes D. Urinary output 35 mL/hr

Correct Answer is C

Explanation

Absent deep tendon reﬂexes are a sign of magnesium toxicity, which can occur with high levels of magnesium in the bloodstream. This can be a serious complication that requires immediate atention from the provider.

Option A, a decrease in frequency of contractions, is actually a desired eﬀect of magnesium sulfate in the management of preterm labor. It is not a cause for concern.

Option B, a blood pressure reading of 150/100 mm Hg, is high, but it is not necessarily related to the administration of magnesium sulfate. However, it should still be reported to the provider for appropriate management.

Option D, a urinary output of 35 mL/hr, is below the normal range but it may still be within an acceptable range for a client receiving magnesium sulfate. The provider should be notified if urinary output continues to decrease or if it falls below a certain threshold.

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A nurse is performing an assessment of a newborn’s Babinski reﬂex. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postpartum and experiencing hypovolemic shock. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is assessing a client who is at 32 weeks of gestation and is receiving magnesium sulphate via continuous IV infusion. Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

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