Examkin

Question

Difficulty: MediumDevelopmental Stages and Transitions

A pediatric nurse is assessing an 8-month-old infant during a routine well-child visit. Which of the following assessment findings is the highest priority for the nurse to report to the pediatric healthcare provider?

  1. The infant exhibits a persistent head lag when pulled from a supine to a sitting position.Answer
  2. B
    The infant begins to cry and reaches for a parent when the nurse approaches the examination table.
  3. C
    The infant uses a raking motion with the whole hand to pick up a small toy block.
  4. D
    The infant babbles a variety of consonant-vowel combinations but does not yet attach specific meaning to words.

Answer

The highest priority finding to report is the infant exhibiting a persistent head lag when pulled from a supine to a sitting position.
By 4 to 6 months of age, an infant should have developed sufficient cervical and trunk muscle tone to maintain their head in alignment with their torso when pulled from a supine to a sitting position. The presence of a persistent head lag at 8 months is a significant developmental red flag that can indicate a severe neuromotor disorder, such as cerebral palsy, or other developmental delays. This requires prompt reporting and further neurological evaluation.

Step-by-Step Solution

1
Identify the expected developmental milestones for an 8-month-old infant.
At 8 months, infants typically exhibit stranger anxiety, use a raking grasp for small objects, and babble nonspecific consonant-vowel sounds.
Establishing the baseline of normal development is necessary to differentiate expected age-appropriate behaviors from potential delays.
2
Evaluate each assessment finding against the expected milestones and identify any developmental red flags.
Crying around strangers, raking small objects, and nonspecific babbling are all normal. However, a head lag should resolve by 4 to 6 months of age.
Comparing findings allows the nurse to identify the single finding that falls outside the normal developmental window and indicates a problem.
3
Determine the clinical significance of a persistent head lag at 8 months.
Its persistence at 8 months indicates a potential neuromotor deficit (such as cerebral palsy), making it the highest priority to report.
Recognizing a significant developmental red flag ensures that appropriate early interventions and referrals are initiated.

Key Concept

Pediatric Developmental Milestones and Red Flags
Rate this question

Topics

Developmental Stages and Transitions

More questions from this topic