Basic Care and Comfort NCLEX RN Nursing Practice Question
The nurse is assessing a six-month-old infant at the clinic. When the nurse strokes from the heel of the foot upward toward the ball, the infant exhibits no movement. Which action is the priority for the nurse?
Correct Answer: B
Rationale: No movement in response to the Babinski reflex (fanning toes) at six months suggests neurological abnormality, warranting a neurology consult (B). Other actions (A, C, D) are less urgent.