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 A
Explanation
Choice A rationale
Retained placental fragments are a significant risk factor for postpartum hemorrhage. If parts of the placenta remain attached to the uterine wall, it can prevent the uterus from contracting properly, leading to excessive bleeding.
Choice B rationale
Breech presentation is not a direct risk factor for postpartum hemorrhage. While it can complicate delivery, it does not directly cause hemorrhage.
Choice C rationale
Urinary tract infection is not a risk factor for postpartum hemorrhage. It can cause other complications but does not directly lead to hemorrhage.
Choice D rationale
Oligohydramnios, or low amniotic fluid, is not a risk factor for postpartum hemorrhage. It can cause complications during pregnancy but does not directly lead to hemorrhage.
Correct Answer is B
Explanation
Choice A rationale
There is no need to fast before a nonstress test. The test measures the fetal heart rate in response to fetal movements and does not require any dietary restrictions.
Choice B rationale
During a nonstress test, the client will press a button whenever they feel the baby move. This helps correlate fetal movements with heart rate changes.
Choice C rationale
The client is not required to lie flat on their back for the duration of the test. They can be in a semi-reclined position to ensure comfort and avoid supine hypotensive syndrome.
Choice D rationale
Medication to stimulate contractions is not used during a nonstress test. This is done during a contraction stress test, which is a different procedure.
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