A nurse is caring for a newborn and assessing newborn reflexes.
To elicit the Babinski reflex, the nurse should take which of the following actions?

Tickle the outer edge of the sole of the newborn’s foot moving up toward the toes.

Turn the newborn’s head quickly to one side.

Hold the newborn vertically allowing one foot to touch the table surface.

Clap near the crib and make a loud noise.

Answer and Explanation

The Correct Answer is A

Choice A rationale

The Babinski reflex is elicited by stroking the outer edge of the sole of the newborn’s foot, moving up toward the toes. This causes the big toe to move upward and the other toes to fan out.

Choice B rationale

Turning the newborn’s head quickly to one side is used to elicit the tonic neck reflex, not the Babinski reflex.

Choice C rationale

Holding the newborn vertically and allowing one foot to touch the table surface is used to elicit the stepping reflex, not the Babinski reflex.

Choice D rationale

Clapping near the crib and making a loud noise is used to elicit the startle (Moro) reflex, not the Babinski reflex.

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Correct Answer is ["7"]

Explanation

The newborn’s Apgar score is 7.

Step 1: Heart rate of 110/min = 2 points.

Step 2: Slow, weak cry = 1 point.

Step 3: Flexed extremities = 1 point.

Step 4: Cries in response to suctioning of the nares = 2 points.

Step 5: Body pink in color with blue extremities = 1 point. Total Apgar score = 2 + 1 + 1 + 2 + 1 = 7.

A. “This is erythema toxicum, which is a transient condition.”. B. “A caput succedaneum occurs due to prolonged pressure of the head against the cervix.”. C. “Mongolian spots can be found on the skin of many newborns.”. D. “This is a cephalhematoma, which can occur spontaneously.”. .

Correct Answer is B

Explanation

Choice A rationale

Erythema toxicum is a common, benign rash in newborns but does not cause swelling that crosses suture lines.

Choice B rationale

A caput succedaneum is swelling of the scalp that crosses suture lines and is caused by prolonged pressure on the head during delivery.

Choice C rationale

Mongolian spots are benign, flat, congenital birthmarks with wavy borders and irregular shapes, typically found on the lower back and buttocks, not the head.

Choice D rationale

A cephalhematoma is a collection of blood between the skull bone and its periosteum that does not cross suture lines. .

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A nurse is caring for a newborn and assessing newborn reflexes.To elicit the Babinski reflex, the nurse should take which of the following actions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["7"]

Explanation

A nurse is caring for a newborn delivered by vaginal birth after 3 hours of pushing.The newborn’s mother asks about the swollen area on her son’s head.After palpation and identification that the swelling does cross the suture line, which of the following is an appropriate response by the nurse?

Correct Answer is B

Explanation

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A nurse is caring for a newborn and assessing newborn reflexes.
To elicit the Babinski reflex, the nurse should take which of the following actions?