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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

(A) Perform fundal massage:
Performing fundal massage is the highest priority action in this scenario. Complete saturation of the perineal pad within 30 minutes postpartum suggests excessive bleeding, which could indicate postpartum hemorrhage (PPH). Fundal massage helps to stimulate uterine contractions, which can aid in controlling bleeding by compressing blood vessels at the placental site. It is essential to assess the fundus for firmness and position and massage it if necessary, to prevent or manage PPH.

(B) Weigh the perineal pad:
Weighing the perineal pad can provide information about the amount of blood loss, but it is not the highest priority action at this moment. Fundal massage takes precedence to address the potential underlying cause of excessive bleeding.

(C) Apply oxygen by face mask:
While oxygen therapy may be indicated in certain situations, such as respiratory distress, it is not the highest priority in this scenario. The priority is to address the potential cause of excessive bleeding and prevent further complications associated with postpartum hemorrhage.

(D) Monitor urine output:
Monitoring urine output is an important aspect of postpartum care, but it is not the highest priority when the client is experiencing excessive bleeding. Addressing the potential cause of bleeding and preventing complications associated with postpartum hemorrhage take precedence.

A. "I will nurse my baby for 5 to 10 minutes on each breast." B. "I will make sure that just the nipple is in my baby's mouth." C. "I will apply vitamin E oil to my nipples after each feeding." D. "I will lay my baby on a pillow at the level of my breast."

Correct Answer is D

Explanation

(A) "I will nurse my baby for 5 to 10 minutes on each breast.":
While nursing for 5 to 10 minutes on each breast might work for some babies, it's generally recommended to allow the baby to nurse as long as they are actively sucking and swallowing. The length of time can vary depending on the baby's needs and the mother's milk supply.

(B) "I will make sure that just the nipple is in my baby's mouth.":
This is incorrect because proper latch-on involves the baby having not just the nipple but also a large portion of the areola in their mouth. This ensures effective milk transfer and helps prevent nipple soreness and damage.

(C) "I will apply vitamin E oil to my nipples after each feeding.":
Applying vitamin E oil or any other substance to the nipples is not typically recommended without the advice of a healthcare provider. Some substances can cause irritation or allergic reactions. Instead, if there is nipple soreness, lanolin or expressed breast milk can be used, but it's best to follow guidelines given by a healthcare provider.

(D) "I will lay my baby on a pillow at the level of my breast.":
Using a pillow to support the baby at the level of the breast can help ensure proper positioning and latch during breastfeeding. This position can make breastfeeding more comfortable for both the mother and the baby, promoting effective feeding and reducing the risk of nipple pain.

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A nurse is checking the reflexes of a newborn. Which of the following actions should the nurse use to elicit the Babinski reflex?

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