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 A
Explanation
Choice A rationale
Repositioning the newborn every 2 to 3 hours is essential during phototherapy to ensure that all areas of the skin are exposed to the light. This helps in the effective breakdown of bilirubin and prevents pressure sores.
Choice B rationale
Monitoring the newborn’s blood glucose level every 2 hours is not a standard intervention for phototherapy. While monitoring glucose levels is important in certain conditions, it is not directly related to the management of hyperbilirubinemia.
Choice C rationale
Applying a water-based ointment to the newborn’s skin every 4 to 6 hours is not recommended during phototherapy. Ointments can block the light from reaching the skin, reducing the effectiveness of the treatment.
Choice D rationale
Giving the newborn 30 mL of distilled water after each feeding is not a recommended practice. Hydration is important, but it should be done through breastfeeding or formula feeding, not distilled water.
Correct Answer is C
Explanation
Choice A rationale
Assessing the client’s socioeconomic status is important for understanding their overall health and access to resources, but it is not directly related to providing information about contraception.
Choice B rationale
Selecting the best method of contraception for the client is not the nurse’s role. The decision should be made by the client based on their individual preferences and health considerations.
Choice C rationale
Performing unbiased teaching is essential for providing accurate and comprehensive information about available methods of contraception. The nurse should present all options without imposing personal beliefs or preferences.
Choice D rationale
Providing information on all available methods is important, but it should be done in an unbiased manner. The nurse should ensure that the client has all the necessary information to make an informed decision.