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Difficulty: MediumData Collection Techniques

While utilizing a developmental screening tool to gather physical data at a 6-month well-child visit, the practical nurse performs the pull-to-sit maneuver and observes other behaviors. Which finding documented during this specific data collection process requires immediate escalation to the registered nurse?

  1. A
    The infant grasps the measuring tape using a whole-hand raking motion.
  2. The infant exhibits pronounced head lag when pulled from a supine to a sitting position.Answer
  3. C
    The infant cries and turns their face away when the unfamiliar nurse attempts auscultation.
  4. D
    The infant cannot independently pull to a standing position on the examination scale.

Answer

The finding that requires immediate escalation is the infant exhibiting pronounced head lag when pulled from a supine to a sitting position.
During developmental data collection, assessing head control is a critical physical technique. An infant should demonstrate no head lag by 4 months of age. The presence of pronounced head lag at 6 months is an abnormal finding that indicates a potential motor or neurological delay, requiring prompt escalation for further evaluation by the registered nurse or provider.

Step-by-Step Solution

1
Identify the client's current age (6 months) and the context of the data collection (developmental screening during a well-child visit).
The nurse must compare observed findings against standard 6-month developmental milestones.
Accurate data collection relies on knowing what is age-appropriate for the client.
2
Evaluate the motor findings gathered during the physical assessment.
A raking grasp and the inability to pull to a stand are normal at 6 months; however, pronounced head lag is abnormal.
Head lag should completely resolve by 4 months of age. Its presence at 6 months is a red flag for motor delays.
3
Evaluate the psychosocial findings gathered during the encounter.
Crying and turning away from an unfamiliar person indicates stranger anxiety, which is normal at this age.
Psychosocial development aligns with expected chronological milestones.
4
Determine which finding is an unexpected deviation from the norm.
The pronounced head lag is the only abnormal finding that requires escalation.
The practical nurse must recognize significant deviations from baseline expectations to report them to the registered nurse or provider.

Key Concept

Normal vs. abnormal pediatric developmental milestones during focused data collection
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Topics

Data Collection Techniques

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