A nurse is collecting data from a newborn.
The nurse should recognize that which of the following images demonstrates a positive Babinski reflex?
Image of a newborn with toes fanning out when the sole of the foot is stroked.
Image of a newborn with toes curling in when the sole of the foot is stroked.
Image of a newborn with no response when the sole of the foot is stroked.
Image of a newborn with the big toe bending down when the sole of the foot is stroked.
The Correct Answer is A
Choice A rationale
A positive Babinski reflex is characterized by the fanning out of the toes and the upward movement of the big toe when the sole of the foot is stroked. This reflex is normal in infants up to 2 years old and indicates an immature central nervous system. The presence of this reflex in older children or adults can indicate neurological issues.
Choice B rationale
Curling in of the toes when the sole of the foot is stroked is indicative of the plantar grasp reflex, not the Babinski reflex. The plantar grasp reflex is a different neurological response and does not indicate the same neurological development as the Babinski reflex.
Choice C rationale
No response when the sole of the foot is stroked could indicate a lack of neurological response or an issue with the sensory or motor pathways. This is not characteristic of a positive Babinski reflex and could be a sign of neurological impairment.
Choice D rationale
The big toe bending down when the sole of the foot is stroked is a normal response in older children and adults, known as the plantar reflex. This response indicates a mature central nervous system and is not characteristic of a positive Babinski reflex in infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Providing additional hydration by offering glucose water is not recommended. Breast milk or formula should be the primary source of hydration for newborns.
Choice B rationale
Monitoring the newborn’s heart rate every 2 hours is not necessary for phototherapy. The focus should be on monitoring bilirubin levels, hydration status, and ensuring the newborn’s eyes are protected.
Choice C rationale
Applying a water-based lotion to the newborn’s skin every 4 hours is not recommended. Lotions can interfere with the effectiveness of phototherapy and may cause skin irritation.
Choice D rationale
Removing the newborn from phototherapy every 2 hours for breastfeeding is recommended. Frequent breastfeeding helps to promote bilirubin excretion and maintain hydration.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Explanation
The nurse should first address the client’sA. Elevated blood pressure, followed by the client’sD. Visual disturbances.
Explanation:
- Elevated blood pressure: This is the most critical issue to address first because it poses an immediate risk to both the mother and the fetus. Severe hypertension can lead to complications such as preeclampsia, eclampsia, or placental abruption. The provider has already prescribed labetalol to manage the blood pressure, which is a priority intervention.
- Visual disturbances: These can be a sign of worsening preeclampsia, which requires close monitoring and prompt intervention. Addressing visual disturbances is crucial to prevent further complications.
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