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
Purchasing furniture for the baby’s room is a common and healthy behavior during pregnancy. It indicates that the client is preparing for the baby’s arrival and is excited about the new addition to the family. This behavior is generally seen as positive and supportive of the pregnancy.
Choice B rationale
Being unsure about wanting an epidural during labor is a normal concern for many pregnant individuals. It reflects the client’s consideration of pain management options and their desire to make an informed decision. This is not typically seen as a psychosocial concern.
Choice C rationale
The partner planning to attend birthing classes with the client is a positive sign of support and involvement in the pregnancy. It indicates that the partner is engaged and willing to participate in the childbirth process, which can be beneficial for the client’s emotional well-being.
Choice D rationale
Expressing uncertainty about whether an older child will accept the new baby can indicate underlying anxiety or stress about family dynamics and the impact of the new baby on existing relationships. This concern may require further exploration and support to ensure the client’s emotional health.
Correct Answer is C
Explanation
Choice A rationale
Agitation is not a common adverse effect of magnesium sulfate therapy. It is more likely to be caused by other factors.
Choice B rationale
Polyuria, or excessive urination, is not a common adverse effect of magnesium sulfate therapy. It is more likely to be caused by other factors.
Choice C rationale
Hyporeflexia, or diminished reflexes, is a significant adverse effect of magnesium sulfate therapy. It indicates magnesium toxicity and requires immediate attention.
Choice D rationale
Tachypnea, or rapid breathing, is not a common adverse effect of magnesium sulfate therapy. It is more likely to be caused by other factors.
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