A nurse is evaluating an infant who received treatment for increased intracranial pressure. Which of the following findings should the nurse identify as an indication that the treatment was effective?

A. No head lag when pulled into a sitting position: By 2 months, some head lag may still be present when pulling the infant to a sitting position. Full control of the head without lag typically develops closer to 4 months of age.

B. Lifts head 45° when lying prone: At 2 months, infants generally can lift and hold their head at about a 45-degree angle when placed on their stomach. This demonstrates early neck muscle strength and control appropriate for this age.

C. Rolls over from abdomen to back: Rolling over usually occurs later, around 4 to 6 months. It is not an expected gross motor milestone for a 2-month-old infant.

D. Rolls over from back to abdomen: This is a more advanced motor skill that typically develops between 5 to 6 months of age and would not be expected at 2 months.

A. Observe abdominal movement to determine the respiratory rate: While observing abdominal movement can help count respirations, in adolescents, chest movement should also be assessed since diaphragmatic breathing is less dominant than in infants.

B. Auscultate the abdomen for at least 1 min if bowel sounds are absent: Bowel sounds should be assessed for a full minute before concluding they are absent; this is standard practice, but it is not a unique action specific to adolescent assessment.

C. Use the FACES scale to assess pain: The FACES pain scale is designed primarily for younger children (typically ages 3 to 8); adolescents generally respond better to numeric or descriptive pain scales.

D. Have the child bend forward at the waist and check for asymmetry of the scapula: This is the recommended screening method for scoliosis, which commonly develops during adolescence; assessing scapular asymmetry during forward bending is appropriate and important for this age group.