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 B
Explanation
Choice A rationale
Erythema toxicum is a common, benign rash in newborns but does not cause swelling that crosses suture lines.
Choice B rationale
A caput succedaneum is swelling of the scalp that crosses suture lines and is caused by prolonged pressure on the head during delivery.
Choice C rationale
Mongolian spots are benign, flat, congenital birthmarks with wavy borders and irregular shapes, typically found on the lower back and buttocks, not the head.
Choice D rationale
A cephalhematoma is a collection of blood between the skull bone and its periosteum that does not cross suture lines. .
Correct Answer is C
Explanation
Choice A rationale
Applying a 1-2 cm ribbon from outer to inner canthus is incorrect because it increases the risk of contamination and infection by moving from a less clean area to a more clean area.
Choice B rationale
Applying a 2-3 inch ribbon from inner to outer canthus is incorrect because the length of the ribbon is too long and the direction is not recommended for preventing contamination.
Choice C rationale
Applying a 1-2 cm ribbon from inner to outer canthus is correct as it minimizes the risk of contamination by moving from a cleaner area to a less clean area, ensuring proper application of the ointment.
Choice D rationale
Applying a 1-2 inch ribbon to the upper eyelid is incorrect because the upper eyelid is not the recommended site for application, and the length of the ribbon is too long.