Difficulty: Medium
Average Score: 92%
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
B
Rationale
The correct answer is B: Doll's eye reflex intact. This reflex, also known as oculocephalic reflex, should not be present in infants beyond 3 months old. It involves the eyes moving in the opposite direction of head movement, which is abnormal in older infants. This finding could indicate a neurological issue and should be reported to the provider for further evaluation.
Choice A is normal as lack of head lag at 4 months indicates appropriate muscle tone. Choice C is normal as infants should start producing tears when crying around this age. Choice D is normal in infants under 2 years old as the Babinski reflex is present until this age.
Choice A is normal as lack of head lag at 4 months indicates appropriate muscle tone. Choice C is normal as infants should start producing tears when crying around this age. Choice D is normal in infants under 2 years old as the Babinski reflex is present until this age.