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 D
Explanation
Choice A rationale
The xiphoid process is not the correct anatomical landmark for measuring chest circumference in newborns. It is located at the lower end of the sternum and does not provide a consistent measurement point.
Choice B rationale
The fifth intercostal space is not used for measuring chest circumference in newborns. This space is located between the ribs and is not a reliable landmark for consistent measurements.
Choice C rationale
The sternal notch is not the correct landmark for measuring chest circumference. It is located at the top of the sternum and does not provide a consistent measurement point.
Choice D rationale
The nipple line is the correct anatomical landmark for measuring chest circumference in newborns. This method ensures that the measurement is taken at a consistent and reproducible location, providing an accurate assessment of the chest size relative to growth and development standards.
Correct Answer is C
Explanation
Choice A rationale
Faint red marks on the plantar surface are more common in preterm infants and are not typically seen in post-term infants.
Choice B rationale
Copious vernix is usually seen in preterm infants. Post-term infants often have little to no vernix.
Choice C rationale
Dry, cracked skin is a common finding in post-term infants due to prolonged exposure to the amniotic fluid.
Choice D rationale
Scant scalp hair is more common in preterm infants. Post-term infants usually have more developed hair.