While performing a physical assessment on a 6-month-old infant, the nurse observes head lag. Which of the following nursing actions should the nurse perform first?
A.
Ask the parents to allow the infant to lay on her stomach to promote muscle development.
B.
Notify the physician because a developmental or neurological evaluation is indicated.
C.
Document the findings as normal in the nurse’s notes.
D.
Explain to the parents that their child is likely to be mentally retarded.
Suggested Answer:B🗳️
Head lag should be completely resolved by 4 months of age. Continuing head lag at 6 months of age indicates the need for further developmental or neurological evaluation. Laying the infant on her stomach promotes muscle development of the neck and shoulder muscles, but because of the age of this child, a referral should be the first action. These findings are not normal for a 6-month-old infant. Significant head lag can be seen in infants with Down syndrome and hypoxia, as well as neurologic and other metabolic disorders. Some of those disorders might have mental retardation as a component. However, this child needs to have the referral to determine the cause of the head lag first. Health Promotion and Maintenance
Currently there are no comments in this discussion, be the first to comment!
This section is not available anymore. Please use the main Exam Page.NCLEX-PN Exam Questions
Log in to ExamTopics
Sign in:
Community vote distribution
A (35%)
C (25%)
B (20%)
Other
Most Voted
A voting comment increases the vote count for the chosen answer by one.
Upvoting a comment with a selected answer will also increase the vote count towards that answer by one.
So if you see a comment that you already agree with, you can upvote it instead of posting a new comment.
Comments