A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Babinski reflex, the nurse should take which of the following actions?
Tickle the outer edge of the sole of the newborn’s foot moving up toward the toes.
Turn the newborn’s head quickly to one side.
Hold the newborn vertically allowing one foot to touch the table surface.
Clap near the crib and make a loud noise.
The Correct Answer is A
Choice A rationale
The Babinski reflex is elicited by stroking the outer edge of the sole of the newborn’s foot, moving up toward the toes. This causes the big toe to move upward and the other toes to fan out.
Choice B rationale
Turning the newborn’s head quickly to one side is used to elicit the tonic neck reflex, not the Babinski reflex.
Choice C rationale
Holding the newborn vertically and allowing one foot to touch the table surface is used to elicit the stepping reflex, not the Babinski reflex.
Choice D rationale
Clapping near the crib and making a loud noise is used to elicit the startle (Moro) reflex, not the Babinski reflex.
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Correct Answer is C
Explanation
Choice A rationale
Depressed fontanelles are not exclusive to premature newborns. They can occur in both premature and full-term infants and are not an indicator of prematurity.
Choice B rationale
Depressed fontanelles do not indicate infection. Infections in newborns typically present with other symptoms such as fever, irritability, and poor feeding.
Choice C rationale
Depressed fontanelles are a sign of dehydration in newborns. When a newborn is dehydrated, the fontanelles can appear sunken due to the lack of fluid in the body.
Choice D rationale
Depressed fontanelles are not a normal finding in newborns. Normally, fontanelles should be flat or slightly curved inward. A depressed fontanelle is a clinical sign that requires further evaluation and intervention.
Correct Answer is B
Explanation
Choice A rationale
Small for gestational age (SGA) refers to newborns whose birth weight is below the 10th percentile for their gestational age.
Choice B rationale
Appropriate for gestational age (AGA) refers to newborns whose birth weight is between the 10th and 90th percentiles for their gestational age. A newborn weighing 3350 g at 39 weeks gestation falls within this range.
Choice C rationale
Low birth weight is defined as a birth weight of less than 2500 g, which does not apply to this newborn.
Choice D rationale
Large for gestational age (LGA) refers to newborns whose birth weight is above the 90th percentile for their gestational age.