A nurse is checking the reflexes of a newborn. Which of the following actions should the nurse use to elicit the Babinski reflex?
Touch the corner of the newborn's mouth.
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.
The Correct Answer is C
(a) Touch the corner of the newborn's mouth:
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 touch and open their mouth, which helps with feeding.
(b) Place the newborn supine and apply pressure to the soles of the feet:
Applying pressure to the soles of the feet is not a method used to elicit the Babinski reflex. This action might influence other reflexes but not the Babinski.
(c) Stroke upward on the lateral aspect of the sole of the newborn's foot:
This is correct. The Babinski reflex is elicited by stroking upward on the lateral aspect of the sole of the newborn's foot. A positive response is the fanning and extension of the toes, which is normal in newborns.
(d) Pull the newborn up by the wrist from a supine position:
Pulling the newborn up by the wrists from a supine position is used to assess the traction response or pull-to-sit maneuver, which tests the newborn's head control and muscle tone, not the Babinski reflex.
Nursing Test Bank
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Related Questions
Correct Answer is C
Explanation
(a) Peanut butter:
Peanut butter is a good source of protein and healthy fats, but it is not particularly high in calcium. While it has some nutritional benefits, it would not significantly contribute to increasing calcium levels.
(b) Avocados:
Avocados are rich in healthy fats, vitamins, and minerals, but they are not a significant source of calcium. They provide numerous other health benefits, but they do not help much with increasing calcium levels.
(c) Yogurt:
Yogurt is an excellent source of calcium. It is highly recommended for individuals needing to increase their calcium intake because it is rich in calcium and also provides protein and probiotics, which are beneficial during pregnancy.
(d) Long-grain rice:
Long-grain rice is a good source of carbohydrates and some vitamins, but it is not a significant source of calcium. Including it in the diet would not effectively help in addressing a low calcium level.
Correct Answer is A
Explanation
(A) Reposition the newborn every 2 to 3 hr:
Repositioning the newborn every 2 to 3 hours helps ensure uniform exposure to the phototherapy lights, maximizing the effectiveness of the treatment. This prevents uneven distribution of light and reduces the risk of pressure ulcers or skin breakdown from prolonged immobility.
(B) Monitor the newborn's blood glucose level every 2 hr:
Monitoring the newborn's blood glucose level every 2 hours is not directly related to phototherapy for hyperbilirubinemia. While monitoring blood glucose levels may be necessary for certain newborns, especially those at risk for hypoglycemia, it is not a routine intervention during phototherapy.
(C) Give the newborn 30 ml of distilled water after each feeding:
Giving the newborn distilled water after each feeding is not indicated during phototherapy for hyperbilirubinemia. Breast milk or formula is sufficient for hydration, and providing additional water can interfere with adequate feeding and potentially lead to electrolyte imbalances.
(D) Apply a water-based ointment to the newborn's skin every 4 to 6 hr:
Applying a water-based ointment to the newborn's skin is not typically recommended during phototherapy. Ointments can create a barrier on the skin, reducing the effectiveness of the phototherapy treatment by blocking light absorption.
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