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?

  • take the infant’s vital signs
  • order a neurology consult
  • examine the infant’s nose and ears
  • ask how much formula the infant consumes daily
Number 2 is correct.
The infant is failing to exhibit the Plantar reflex, or Babinski’s sign. This is a normal reflex present until 1 year of age. Lack of the reflex indicates the need for further neurological assessment by the health care provider. Taking the infant’s vital signs is a necessary part of every visit but is not the priority here. Examining the nose and ears is not indicated at this time and is not as urgent as determining if the infant has neurological deficits. Determining how well the infant feeds is important to track, but is not the primary concern for this client.