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    Wgu rn hesi health assessment proctored exam

    When assessing the left foot planter reflex of an adult client, the nurse observes an extension of the great toe and fanning of other toes Which interpretation of this finding is accurate?

    Explanation & Rationale

    A. A normal reflex response does not include a positive Babinski sign. B. An exaggerated reflex response refers to hyperreflexia, which can be seen in conditions like upper motor neuron lesions but does not specifically describe the Babinski sign. C. Meningeal irritation would typically cause signs such as neck stiffness or photophobia, not a positive Babinski sign. D. The extension of the great toe and fanning of other toes is a positive Babinski sign, which is abnormal in adults and typically suggests pyramidal tract disease (upper motor neuron lesion).

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