A nurse is performing an assessment of a newborn's Babinski reflex. Which of the following findings should the nurse expect?
Flexion of the forearm.
Downward curl of the toes.
Dorsiflexion of the great toe.
Extension of the leg.
The Correct Answer is C
The Babinski reflex, also known as the plantar reflex, is a normal reflex in infants
that occurs when the sole of the foot is stroked from heel to toe.
In response to this stimulus, the big toe moves upward or toward the top surface of the foot and the other toes fan out.
Choice A is not an answer because flexion of the forearm is not a response to stimulation of the foot.
Choice B is not an answer because downward curl of the toes is not a response
to stimulation of the foot.
Choice D is not an answer because extension of the leg is not a response to
stimulation of the foot.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationales
A. Rust-stained urine.
Rust or brick-dust staining in the diaper is usually caused by urate crystals in the urine. This is a common and benign finding in newborns during the first days of life, particularly when fluid intake is still low. It does not require provider notification unless it persists beyond the first week or is accompanied by other abnormalities.
B. Subconjunctival hemorrhage.
A subconjunctival hemorrhage often results from pressure during delivery, especially in vaginal births. It appears as a bright red patch on the sclera but is harmless and resolves spontaneously within several weeks. It is considered a normal newborn finding and does not need to be reported.
C. Single palmar creases.
A single transverse palmar crease, also known as a simian crease, can be associated with chromosomal abnormalities such as Down syndrome. While it may sometimes be an isolated normal variant, its presence warrants further evaluation. The nurse should report this finding to the provider for assessment and potential genetic follow-up.
D. Transient circumoral cyanosis.
Brief bluish discoloration around the lips in a newborn is typically due to vasomotor instability and is common when the infant is crying or cold. As long as the central mucous membranes remain pink and oxygenation is normal, this finding is not concerning and usually resolves without intervention.
Correct Answer is C
Explanation
A nurse assessing the results of a nonstress test for an antepartal client at 35 weeks of gestation should indicate the need for further diagnostic testing if there are no late decelerations noted with three uterine contractions of 60 seconds in duration within a 10-min testing period.
Choice A is incorrect because an increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period is a normal result.
Choice B is incorrect because irregular contractions of 10 to 20 seconds in duration that are not felt by the client do not indicate the need for further diagnostic testing.
Choice D is incorrect because three fetal movements perceived by the client in a 20-min testing period do not indicate the need for further diagnostic testing.
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