RN Nursing Basic Care and Comfort Related

Review RN Nursing Basic Care and Comfort related questions and content

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?

  • A. take the infant's vital signs
  • B. order a neurology consult
  • C. examine the infant's nose and ears
  • D. ask how much formula the infant consumes daily
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.