A nurse in the pediatrician's office is checking the
Babinski reflex in a 3-month-old infant. The nurse determines
that the infant's response is normal if which of the following
findings is noted?
A
B
C
D
The infant turns to the side that is touched.
The fingers curl tightly and the toes curl forward.
The toes flare and the big toe is dorsiflexed. Correct
There is extension of the extremities on the side to which the
head is turned, with flexion on the opposite side.
□
□ Rationale: To elicit the Babinski reflex, the nurse strokes
the lateral sole of the foot from the heel to across the base
of the toes. In the expected response, the toes flare and the
big toe dorsiflexes. The Babinski reflex disappears at 12
months of age. Turning to the side that is touched is the
expected response when the rooting reflex is elicited. Tight
curling of the fingers and forward curling of the toes is the
expected response when the grasp reflex (palmar and
plantar) is elicited. Extension of the extremities on the side
to which the head is turned with flexion on the opposite side
is the expected response when the tonic neck reflex is
elicited.
□ Test-Taking Strategy: Knowledge regarding the method
of testing and the expected response of the Babinski reflex is
needed to answer this question. Recalling that to elicit
Babinski reflex the nurse would stroke the lateral sole of the
foot will direct you to the correct option. Review the
procedure for testing this reflex in an infant and the
expected response if you had difficulty with this question.
□
□ Reference: McKinney, E., James, S., Murray, S., &
Ashwill, J. (2009). Maternal-child nursing (3rd ed., p. 516). St.
Louis: Elsevier.
ati ati comprehensive predictor ati pharmacology proctored community health comprehensive fundamentals health care health care / nursing health care/ nursing healthcare hesi hesi rn exit leadership maternal newborn med surg medical surgical mental health nurs nursing nursing & health nutrition pediatrics pharmacology test bank tncc
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