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 D
Explanation
Choice A rationale
Stretching arms out and then back in is a common reflex in newborns known as the Moro reflex. It is not a sign of feeding readiness but rather a response to a sudden loss of support or a loud noise.
Choice B rationale
Turning the head toward a parent’s voice is a sign of auditory recognition and bonding, not necessarily feeding readiness. It indicates the infant’s ability to recognize familiar sounds.
Choice C rationale
Grasping a parent’s finger when placed in the infant’s palm is a primitive reflex known as the palmar grasp reflex. It is not related to feeding readiness but is a normal reflexive action in newborns.
Choice D rationale
Bringing their hand to their mouth is a sign of feeding readiness. This action indicates that the infant is hungry and ready to feed. It is an early cue that the baby is ready to eat.