A nurse is assessing a 4-month-old infant during a well-baby visit. For which of the following findings should the nurse notify the provider?
Doll's eye reflex intact
No head lag when pulled to a sitting position
Positive Babinski reflex
Presence of tears when crying
The Correct Answer is A
A. The doll's eye reflex, or oculocephalic reflex, is a normal reflex in infants up to about 2 months of age. It involves the eyes moving in the opposite direction of head movement. By 4 months of age, this reflex
typically disappears as the infant’s voluntary eye movements become more developed. Therefore, if the
B. By 4 months of age, it is normal for an infant to show significant reduction in head lag when pulled to a sitting position. Ideally, the infant should be able to hold their head up with minimal lag.
C. The Babinski reflex is a normal reflex in infants, where the toes fan out when the sole of the foot is stroked. This reflex is expected to be positive in infants up to about 12-24 months of age. By 4 months, a positive Babinski reflex is still normal and does not indicate a problem.
D. Infants typically start producing tears around 2-3 months of age. By 4 months, the presence of tears when crying is a normal developmental milestone and indicates healthy lacrimal gland function. Therefore, this finding is normal and does not need to be reported to the provider.
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Related Questions
Correct Answer is D
Explanation
A. HPV vaccine is typically recommended for adolescents to prevent HPV-related cancers.
B. The IPV series is usually completed by the age of 6-18 months.
C. The Hepatitis B series is typically completed by the age of 6-18 months.
D. The first dose of the varicella (chickenpox) vaccine is typically administered at 12 months of age.
Correct Answer is B
Explanation
A. Lotions, powders, or ointments should be avoided under the harness as they can irritate the skin.
B. This helps protect the skin and keeps the harness clean.
C. Only a healthcare provider should adjust the harness straps. Parents should not attempt to do this.
D. Massage can irritate the skin and should be avoided.
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