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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

(a) Serum bilirubin:
While serum bilirubin can provide useful information about liver function, it is not the most immediate concern for a client with hyperemesis gravidarum. This condition primarily involves severe nausea and vomiting, which can lead to dehydration and ketosis.

(b) Liver enzymes:
Liver enzymes can be elevated in hyperemesis gravidarum, but they are not the primary concern. The immediate priority is to assess the extent of dehydration and metabolic disturbances.

(c) Urinalysis for ketones:
This test is the priority because it helps determine the extent of dehydration and ketosis. In hyperemesis gravidarum, severe vomiting can lead to significant fluid and electrolyte imbalances and ketosis, which need to be identified and corrected promptly to prevent further complications.

(d) CBC:
A complete blood count (CBC) provides useful information about overall health and can identify anemia or infection, but it is not the priority for immediate assessment of hyperemesis gravidarum. The immediate need is to evaluate hydration status and ketosis, which is best done through urinalysis for ketones.

A. "You will not be able to eat or drink anything for 8 hours prior to the test." B. "You will be required to lie flat on your back for the duration of the test C. "You will receive medication through an IV line to stimulate contractions." D. "You will press the provided button when you feel the baby moving during the test.

Correct Answer is D

Explanation

(a) "You will not be able to eat or drink anything for 8 hours prior to the test."
There are no fasting requirements for a nonstress test. The client can eat and drink normally before the test. Nonstress tests do not require the same preparation as some other medical tests, such as fasting or dietary restrictions.

(b) "You will be required to lie flat on your back for the duration of the test."
Lying flat on the back can cause supine hypotension syndrome in pregnant women, which can lead to decreased blood flow to the fetus. Instead, clients are typically positioned in a semi-Fowler's or lateral position to avoid this issue.

(c) "You will receive medication through an IV line to stimulate contractions."
This describes a contraction stress test, not a nonstress test. A nonstress test involves monitoring the fetal heart rate in response to natural fetal movements without inducing contractions through medication.

(d) "You will press the provided button when you feel the baby moving during the test."
During a nonstress test, the client is instructed to press a button whenever they feel fetal movement. This helps the healthcare provider correlate fetal movements with changes in the fetal heart rate, which can indicate fetal well-being.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the admission of a client who has hyperemesis gravidarum. Which of the following laboratory tests is the priority to complete?

Correct Answer is C

Explanation

A nurse in a provider's office is reinforcing teaching with a client who is pregnant and is scheduled for a nonstress test. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

A nurse is assisting in planning care for a newborn who is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse recommend?

A nurse in a prenatal clinic is reinforcing teaching with a client who is at 20 weeks of gestation and has a low calcium level. Which of the following foods should the nurse recommend the client increase in her diet?

A nurse is caring for a client who inquires about available methods of contraception. Which of the following actions should the nurse take?

A nurse is collecting data from a client who has hyperemesis gravidarum. Which of the following findings should the nurse anticipate?

A nurse in a provider's office is collecting data from a client who is at 34 weeks of gestation and reports having a sudden gush of vaginal fluid. Which of the following manifestations is the priority?

A nurse is reinforcing teaching with a client about various contraceptive methods. Which of the following statements should the nurse include in the teaching?

A nurse is reinforcing teaching with a client who is at 10 weeks of gestation regarding the purposes of laboratory tests. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is contributing to the plan of care for a newborn who requires phototherapy for hyperbilirubinemia. Which of the following interventions should the nurse recommend including in the plan?