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

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.

Touch the corner of the newborn’s mouth.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Placing the newborn supine and applying pressure to the soles of the feet is not the correct method to elicit the Babinski reflex. This action does not stimulate the appropriate nerve pathways involved in the reflex.

Choice B rationale

Stroking upward on the lateral aspect of the sole of the newborn’s foot is the correct method to elicit the Babinski reflex. This action stimulates the plantar reflex, causing the big toe to extend upward and the other toes to fan out.

Choice C rationale

Pulling the newborn up by the wrist from a supine position is used to elicit the traction response, not the Babinski reflex. The traction response involves the newborn flexing their arms and attempting to lift their head.

Choice D rationale

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 stimulus and open their mouth.

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Correct Answer is D

Explanation

Choice A rationale

Auscultating the newborn’s bowel sounds is important for assessing gastrointestinal function, but it is not the first priority in managing a newborn with neonatal abstinence syndrome (NAS). Initial care should focus on stabilizing the newborn and addressing withdrawal symptoms.

Choice B rationale

Swaddling the newborn in blankets can help provide comfort and reduce excessive stimulation, which is beneficial for newborns with NAS. However, it is not the first priority. The primary focus should be on assessing and stabilizing the newborn’s vital signs.

Choice C rationale

Weighing the newborn’s wet diaper is important for monitoring fluid balance and hydration status, but it is not the first priority in managing NAS. Initial care should focus on stabilizing the newborn and addressing withdrawal symptoms.

Choice D rationale

Determining the newborn’s respiratory rate is the first priority in managing a newborn with NAS. Assessing and stabilizing the newborn’s vital signs, including respiratory rate, is crucial to ensure the newborn’s immediate health and safety. .

A. Reposition the newborn every 2 to 3 hours. B. Monitor the newborn’s blood glucose level every 2 hours. C. Apply a water-based ointment to the newborn’s skin every 4 to 6 hours. D. Give the newborn 30 mL of distilled water after each feeding.

Correct Answer is A

Explanation

Choice A rationale

Repositioning the newborn every 2 to 3 hours is essential during phototherapy to ensure that all areas of the skin are exposed to the light. This helps in the effective breakdown of bilirubin and prevents pressure sores.

Choice B rationale

Monitoring the newborn’s blood glucose level every 2 hours is not a standard intervention for phototherapy. While monitoring glucose levels is important in certain conditions, it is not directly related to the management of hyperbilirubinemia.

Choice C rationale

Applying a water-based ointment to the newborn’s skin every 4 to 6 hours is not recommended during phototherapy. Ointments can block the light from reaching the skin, reducing the effectiveness of the treatment.

Choice D rationale

Giving the newborn 30 mL of distilled water after each feeding is not a recommended practice. Hydration is important, but it should be done through breastfeeding or formula feeding, not distilled water.

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