A nurse is collecting data from a newborn.
The nurse should recognize that which of the following images demonstrates a positive Babinski reflex?
Image showing toes fanning out when the sole is stroked.
Image showing the newborn grasping a finger when the palm is touched.
Image showing the newborn turning the head when the cheek is stroked.
Image showing the newborn making stepping movements when held upright.
The Correct Answer is A
Choice A rationale
The image showing toes fanning out when the sole of the foot is stroked demonstrates a positive Babinski reflex. This reflex is normal in newborns and indicates immature nervous system development.
Choice B rationale
The image showing the newborn grasping a finger when the palm is touched demonstrates the palmar grasp reflex, not the Babinski reflex. This reflex is also normal in newborns but is unrelated to the Babinski reflex.
Choice C rationale
The image showing the newborn turning the head when the cheek is stroked demonstrates the rooting reflex, not the Babinski reflex. This reflex helps the newborn locate the breast or bottle for feeding.
Choice D rationale
The image showing the newborn making stepping movements when held upright demonstrates the stepping reflex, not the Babinski reflex. This reflex mimics walking and is normal in newborns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"}}
Explanation
Betamethasone 12 mg IM now and repeat in 24 hr:
Anticipated: Betamethasone is a corticosteroid given to pregnant women at risk of preterm labor (before 37 weeks gestation) to help accelerate fetal lung maturity. Since the client is at 32 weeks gestation and suspected of having an infection, administering betamethasone is appropriate to prepare the fetus for potential early delivery.
Position the client supine:
Contraindicated: Positioning a laboring client supine can reduce venous return and cardiac output, potentially compromising uterine perfusion and fetal oxygenation. It can also increase the risk of supine hypotensive syndrome. Therefore, it is contraindicated, and alternative positions such as the left lateral position are recommended.
Terbutaline 0.25 mg Subcutaneous now:
Anticipated: Terbutaline is a tocolytic agent used to delay preterm labor by relaxing the uterus. Given that the client is at 32 weeks gestation and may be experiencing labor due to infection, administering terbutaline can help delay labor while addressing the infection and improving fetal outcomes.
Collect a urine sample:
Anticipated: Collecting a urine sample is a standard procedure to evaluate the client's overall health status and identify any potential infections. It can provide valuable information for diagnosing and managing the suspected infection during labor.
Correct Answer is A
Explanation
Choice A rationale
Placing a newborn in the supine position (on their back) is recommended to reduce the risk of sudden infant death syndrome (SIDS). This safe sleep practice has been proven to significantly lower the risk of SIDS.
Choice B rationale
Placing a newborn in the left lateral position is not recommended as the primary position for sleep, as it does not offer the same protective benefits against SIDS as the supine position.
Choice C rationale
Placing a newborn in the right lateral position similarly does not provide the same reduction in SIDS risk as the supine position. Side-lying positions can lead to rolling into a prone position, increasing the risk.
Choice D rationale
Placing a newborn in the prone position (on their stomach) is associated with a higher risk of SIDS. This position is not recommended for sleep due to the increased risk of respiratory compromise.
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