A nurse is reviewing the laboratory results of a child who was recently admitted for suspected rheumatic fever.

The nurse should identify that which of the following laboratory tests can contribute to confirming this diagnosis? (Select all that apply.)

The first action the nurse should take is to assess the respiratory status of the infant.

After a head injury, it is important to ensure that the child’s airway is clear and that they are breathing adequately.

This is a crucial step in providing care for a patient with a head injury.

Choice B is wrong because inspecting for fluid leaking from the ears is not the first priority.

Choice C is wrong because examining the scalp for lacerations is not the first priority.

Choice D is wrong because checking pupil reactions is not the first priority.

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.