Difficulty: Medium
Average Score: 90%
Simulated
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?
Correct answer
D
Rationale
The correct answer is D, no head lag when pulled to a sitting position. This finding indicates a lack of normal head control for a 4-month-old infant, which may suggest developmental delays or muscular weakness. The other choices are considered normal findings for a 4-month-old infant. A positive Babinski reflex, presence of tears when crying, and intact Doll's eye reflex are all expected developmental milestones at this age. Therefore, notifying the provider about the lack of head lag is essential for further evaluation and intervention.