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
A newborn who is 10 hr old and has onset tachypnea.
Tachypnea means rapid breathing and can be a sign of respiratory distress.
Transient tachypnea of the newborn (TTN) is a respiratory disorder usually seen shortly after delivery in babies who are born near or at term.
It is important for the nurse to assess this newborn first to determine the cause of the tachypnea and provide appropriate care.
Choice A, a newborn who is 24 hr old and has not had a meconium stool, may
require further assessment but is not as urgent as a newborn with tachypnea.
Choice B, a newborn who has a short frenulum and is having difficulty breastfeeding, may require assistance with feeding but is not as urgent as a newborn with tachypnea.
Choice D, a newborn who is 30 hr old and has blood-tinged discharge in her diaper, may have pseudomenstruation which is normal and not a cause for concern.
Correct Answer is B
Explanation
“Use an automatic puncture device on the heel.” This is the most common and minimally invasive method to draw capillary blood from an infant for medical testing.
Choice A is incorrect because the heel should be punctured on the outer aspect of the foot to avoid damaging the calcaneus bone.
Choice C is incorrect because the heel should be cleansed with an alcohol swab
before, not after, the procedure.
Choice D is incorrect because there is no need to place an ice pack on the newborn’s heel before the procedure.
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