A nurse is preparing to administer recommended immunizations to a 12-month-old infant who is up-to-date with the current schedule. Which of the following immunizations should the nurse plan to administer?Select all that apply.

Rationale:

A. Capillary refill time of 3 seconds is within the normal range (less than 3 seconds) and does not indicate severe dehydration.

B. A sunken anterior fontanel is a significant sign of dehydration in infants and suggests severe dehydration.

C. While a weight loss of 5% can indicate dehydration, it may not necessarily represent severe dehydration. The extent of dehydration is better assessed by clinical signs such as fontanel status, skin turgor, and mucous membrane moisture.

D. Producing tears when crying is a reassuring sign and suggests adequate hydration, so it does not indicate severe dehydration.

Rationale:

A. Rolling over from back to abdomen typically occurs around 4 to 6 months of age.

While it may be slightly delayed, it is not usually concerning at 5 months.

B. Head lag at 5 months is abnormal and may indicate weakness or poor muscle tone, warranting further evaluation by the healthcare provider.

C. Not all infants are able to hold a bottle at 5 months, and this finding alone may not be concerning.

D. The grasp reflex typically diminishes by 3 to 4 months of age, so it may not be present at 5 months. While it's a developmental milestone, its absence alone may not warrant immediate concern at this age.