A nurse is monitoring an infant who is receiving opioids for pain.
Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect?

The correct answer is d. Exhibits head lag when pulled to a sitting position.

Choice A: Unable to hold a bottle At around 6 months of age, some babies can hold their own bottle. This is not a concerning finding for a 5-month-old infant. Therefore, this is not the correct answer.

Choice B: Unable to roll from back to abdomen Rolling over often starts around 4-6 months, so it’s not unusual for a 5-month-old to still be developing this skill. Therefore, this is not the correct answer.

Choice C: Absent grasp reflex The grasp reflex is an involuntary movement that your baby starts making in utero and continues doing until around 6 months of age. The grasp reflex lasts until the baby is about 5 to 6 months old. Therefore, this is not the correct answer.

Choice D: Exhibits head lag when pulled to a sitting position By the age of 5 months, most infants have developed enough strength in their neck and upper body to control their head movement. This means they should not exhibit a significant head lag when pulled to a sitting position1. If this is not the case, it could indicate a delay in motor development or a potential neurological issue, which should be reported to the healthcare provider for further evaluation. Therefore, this is the correct answer.

The correct answer is choice C. Elevate the infant’s head to a 10° angle during feedings.

This position can help prevent milk from coming out of the infant’s nose and reduce the risk of choking.

Choice A is wrong because watery eyes are not an indication to discontinue feeding.

Choice B is wrong because babies with cleft palate should be burped more frequently, but not so often as to interrupt good feeding behaviors.

Choice D is wrong because the amount of formula an infant needs varies and should be determined by a pediatrician.