A nurse is assessing a 6-month-old infant. Which of the following findings should the nurse report to the provider?
Inability to sit without support
Inability to feed himself
Inability to raise head when in prone position
Inability to stand alone without support
The Correct Answer is C
The inability to raise the head when in a prone position is a finding that the nurse should report to the provider. By 6 months of age, infants should typically be able to raise their head and chest off the surface when placed in a prone position. This is an important milestone in motor development and is known as "head control." The nurse should report this finding to the provider to ensure further assessment and appropriate intervention if necessary.
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Related Questions
Correct Answer is C
Explanation
A. It’s usually best to build trust and rapport first with non-invasive assessments. Starting with a potentially uncomfortable procedure like looking in the ears may cause distress and make the rest of the exam more difficult.
B.Examining the tympanic membrane before the head and neck might still be too early in the assessment and could cause the child to become uncooperative for subsequent steps. If the child becomes upset, it could complicate the rest of the physical exam, making it harder to complete.
C.Performing the ear examination at the end allows the nurse to build trust and rapport throughout the visit. The child is less likely to become distressed too early in the exam, which helps maintain cooperation for as long as possible.If the child does become upset, it is at the end of the visit, and the more critical assessments have already been completed.
D.If the ear exam causes distress, it may make the child uncooperative for important assessments like auscultating the heart and lungs.
Correct Answer is C
Explanation
By 15 months of age, toddlers typically develop the ability to stand and maintain balance without support. This milestone is an important indicator of gross motor development. Not being able to stand upright without support at this age may suggest a delay or impairment in motor skills, and further evaluation may be needed to determine the underlying cause.
The other findings mentioned—difficulty jumping with both feet, inability to build a tower of six to seven cubes, and inability to turn a doorknob—are within the expected range of development for a 15-month-old toddler. While some children may already demonstrate these skills, others may acquire them later in their developmental journey. It is important to consider individual variations in development, but the inability to stand without support should be further assessed.
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