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 D

Explanation

(A) Ask a parent to state the newborn's date of birth:
While asking a parent to state the newborn's date of birth may seem like a reasonable step, it relies on the parent's memory and verbal confirmation, which may not always be accurate. It's possible for a parent to forget or provide incorrect information, leading to potential identification errors.

(B) Check the newborn's footprint sheet with the medical record:
Footprint identification is a common practice in hospitals, but it may not always be feasible or practical during routine newborn transport to parents. Additionally, relying solely on footprints for identification may not be as reliable as comparing identification bands, as footprints can smudge or be difficult to match accurately.

(C) Request a parent to verify the newborn's name:
Asking a parent to verify the newborn's name relies on verbal confirmation, similar to option A. While it may provide some level of reassurance, it is not as reliable as comparing identification bands to confirm identity. Additionally, newborns may not yet have been formally named at the time of transport.

(D) Compare numbers on the newborn's band to the parent's band:
Comparing the identification numbers on the newborn's identification band with those on the parent's identification band is the most reliable method to confirm the newborn's identity. This process ensures that the newborn is matched with the correct parent(s) before handing over the infant. It helps prevent instances of newborn mix-up or abduction.

A. "You should recognize that your baby sucking on his hands is a hunger cue." B. "You should feed your baby for 10 minutes on each breast.” C. "You should feed your baby six times a day." D. "You should wake your baby at least every 6 hours at night for feedings."

Correct Answer is A

Explanation

(A) "You should recognize that your baby sucking on his hands is a hunger cue."
Recognizing hunger cues is crucial for successful breastfeeding. Early hunger cues like sucking on hands, rooting, and lip-smacking indicate that the baby is ready to feed. Responding to these cues can help establish a good breastfeeding routine and ensure the baby gets adequate nutrition before becoming too distressed to feed effectively.

(B) "You should feed your baby for 10 minutes on each breast."
Feeding duration can vary significantly among babies. Some may need longer than 10 minutes on each breast, while others might feed more efficiently in a shorter time. Instead of a strict time limit, it's important to encourage the mother to allow the baby to feed until they show signs of being full, such as pulling away from the breast or falling asleep.

(C) "You should feed your baby six times a day."
Newborns typically need to feed more frequently than six times a day. Most newborns breastfeed 8-12 times in 24 hours. Limiting feeds to six times a day may not provide sufficient nutrition and can affect the baby’s growth and milk supply.

(D) "You should wake your baby at least every 6 hours at night for feedings."
Newborns, especially in the first few weeks, often need to be fed more frequently than every 6 hours, including at night. Typically, it’s recommended to wake a baby to feed if they sleep for more than 4 hours at a time in the early weeks to ensure adequate intake and to help establish the mother’s milk supply.

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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?

Nursing Test Bank

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