NCLEX-RN

Category - Health Promotion

Which of the following actions should the nurse take to assess for the plantar reflex?
  1. With the infant supported in an upright position, slowly lower the infant onto a flat and firm surface, letting his feet touch the surface.
  2. As the infant lies on his back, turn his head to one side.
  3. Stroke the lateral side of the sole from the back of the heel to the base of the toes.
  4. The infant is positioned face down in water.
Explanation
Answer: C - Plantar reflex is the plantar flexion of the big toe and flexion and adduction of the smaller toes. This reflex is in contrast to Babinski’s reflex, where the smaller toes fan out and the big toe goes up. Plantar reflex is elicited by stroking the lateral or external area of the sole from the back of the heels to the base of the toes. Option A refers to stepping reflex, option B refers to tonic neck reflex, and option D refers to swimming reflex.
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