The nurse is assessing an infant's extrusion reflex. To perform this correctly, what steps does the nurse take?
A.
Place a small object in the infant's hand.
B.
Stroke the side of the infant's cheek.
C.
Touch the tip of the infant's tongue.
D.
Turn the infant's head to one side.
ANS: C
The extrusion reflex is elicited by touching the tip of the infant's tongue. The tongue should protrude outward. Palmar grasp is detected by placing a small object in the infant's hand. Stroking the side of the cheek should result in the rooting reflex. Turning the head and watching the position of the extremities is part of the tonic neck or fencing reflex.
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