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 B

Explanation

Answer: B. Determine the newborn's respiratory rate.

Rationale:

A. Weigh the newborn's wet diaper:
While monitoring fluid output is important in assessing hydration status and overall health, it is not the immediate priority. In the context of a newborn with neonatal abstinence syndrome (NAS), the respiratory status takes precedence, especially given that withdrawal can affect respiratory function.

B. Determine the newborn's respiratory rate:
Assessing the respiratory rate is crucial, as newborns with NAS may experience respiratory distress, including increased respiratory effort or apnea. Identifying any respiratory issues early allows for prompt intervention, which is vital for the newborn's safety and well-being. Ensuring adequate respiratory function is a priority in this population.

C. Auscultate the newborn's bowel sounds:
While assessing bowel sounds is relevant to monitoring gastrointestinal function and potential withdrawal symptoms, it is not the immediate priority. Changes in bowel sounds may occur due to the syndrome, but respiratory assessment should come first to ensure stability.

D. Swaddle the newborn in blankets:
Swaddling can provide comfort to a newborn with NAS; however, it is not the first action to take. Comfort measures are important, but they should follow critical assessments of the newborn's respiratory and overall clinical status to ensure safety.

A. Restrict fluids to 1,000 mL/day. B. Take an over-the-counter antacid C. Increase intake of fresh fruits D. Eat dry, bland foods in the morning

Correct Answer is D

Explanation

(A) Restrict fluids to 1,000 mL/day:
Restricting fluids may lead to dehydration, which can exacerbate nausea and other symptoms of morning sickness. It is important for pregnant individuals to stay hydrated, so fluid restriction is not recommended unless otherwise directed by a healthcare provider.

(B) Take an over-the-counter antacid:
While antacids may provide relief for heartburn or indigestion, they are not typically recommended as a first-line treatment for nausea associated with morning sickness. Antacids may have limited effectiveness in managing nausea, and their use should be guided by a healthcare provider.

(C) Increase intake of fresh fruits:
While fresh fruits are nutritious and provide essential vitamins and minerals, they may not be well-tolerated by individuals experiencing morning sickness, especially if they have strong flavors or odors. Encouraging the client to eat bland foods in the morning may be more effective in managing nausea during early pregnancy.

(D) Eat dry, bland foods in the morning:
Encouraging the client to eat dry, bland foods in the morning can help alleviate nausea associated with morning sickness. These foods are generally easier on the stomach and less likely to trigger nausea compared to richer or spicier foods. Examples include crackers, toast, or dry cereal. Eating small, frequent meals throughout the day can also help manage nausea associated with pregnancy.

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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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Naxlex Comprehensive Predictor Exams

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Explanation

Rationale:

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Explanation

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