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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.
Correct Answer: B
Explanation/Reference:
Explanation:
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
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