A nurse is checking the reflexes of a newborn.Which of the following actions should the nurse use to elicit the Babinski reflex?
Place the newborn supine and apply pressure to the soles of the feet.
Stroke upward on the lateral aspect of the sole of the newborn’s foot.
Pull the newborn up by the wrist from a supine position.
Touch the corner of the newborn’s mouth.
The Correct Answer is B
Choice A rationale
Placing the newborn supine and applying pressure to the soles of the feet is not the correct method to elicit the Babinski reflex. This action does not stimulate the appropriate nerve pathways involved in the reflex.
Choice B rationale
Stroking upward on the lateral aspect of the sole of the newborn’s foot is the correct method to elicit the Babinski reflex. This action stimulates the plantar reflex, causing the big toe to extend upward and the other toes to fan out.
Choice C rationale
Pulling the newborn up by the wrist from a supine position is used to elicit the traction response, not the Babinski reflex. The traction response involves the newborn flexing their arms and attempting to lift their head.
Choice D rationale
Touching the corner of the newborn’s mouth elicits the rooting reflex, not the Babinski reflex. The rooting reflex causes the newborn to turn their head toward the stimulus and open their mouth.
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Correct Answer is D
Explanation
Choice A rationale
A BP of 132/84 mm Hg is within the normal range for a pregnant woman and does not require immediate reporting.
Choice B rationale
A weight gain of 1 kg (2.2 lb) in one month is within the expected range for a pregnant woman at 26 weeks gestation.
Choice C rationale
Pedal edema is a common symptom in pregnancy and is usually not a cause for concern unless accompanied by other symptoms.
Choice D rationale
Double vision is a concerning symptom that could indicate a serious condition such as preeclampsia. It should be reported to the provider immediately.
Correct Answer is D
Explanation
Choice A rationale
Applying a corticosteroid cream is not appropriate for acute perineal pain. It is more suitable for chronic inflammation or skin conditions.
Choice B rationale
Increasing fluid intake is beneficial for overall health, but it does not directly address acute perineal pain.
Choice C rationale
Catheterizing the bladder is not indicated for perineal pain unless there is a specific issue with urinary retention.
Choice D rationale
Offering an ice pack helps reduce swelling and numb the area, providing immediate relief for acute perineal pain. It is a standard intervention for postpartum perineal discomfort.