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Difficulty: MediumDevelopmental Stages and Transitions

A practical nurse is assigned to a home healthcare visit to observe a 6-month-old infant's progress. As the infant interacts with the environment, which finding should the nurse recognize as a developmental delay that must be reported to the supervising registered nurse?

  1. The infant's head falls backward when pulled from a supine to a seated position.Answer
  2. B
    The infant uses the entire palm of the hand to pick up a rattle.
  3. C
    The infant begins to cry vigorously when the nurse attempts to hold them.
  4. D
    The infant babbles using single consonant-vowel combinations.

Answer

The infant's head falling backward when pulled from a supine to a seated position indicates a developmental delay.
By 4 months of age, an infant should have established head control with no head lag when pulled to a sitting position. The presence of a head lag at 6 months is a significant red flag for a gross motor or neurological delay and must be reported immediately.

Step-by-Step Solution

1
Analyze the client's current chronological age.
The infant is exactly 6 months old.
Developmental milestones are evaluated based on chronological age to determine expected versus delayed progress.
2
Evaluate the motor, psychosocial, and language findings presented in the options against expected 6-month milestones.
Palmar grasp, stranger anxiety, and babbling are normal developmental findings at 6 months. Pronounced head lag is abnormal.
Differentiating between expected transitions and genuine delays is essential for safe practical nursing care.
3
Identify the specific finding that requires reporting.
Head lag at 6 months requires intervention because infants should have full head control by 4 months of age.
Identifying missing milestones allows the nurse to promptly report the deviation to the supervising RN for further provider evaluation.

Key Concept

Normal infant developmental milestones and identification of developmental delays.
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Topics

Developmental Stages and Transitions

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