NCLEX-PN
Health Promotion and Maintenance NCLEX Questions Questions
Extract:
Question 1 of 5
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?
Correct Answer: B
Rationale: 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 his 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. The findings are abnormal for a 6-month-old infant. Significant head lag can be seen in infants with Down syndrome and hypoxia, as well as neurological and other metabolic disorders. While some of these disorders might include developmental delays, stating this to the parents without a proper evaluation can cause unnecessary distress. The priority is to identify the cause of the head lag through a medical evaluation before discussing potential outcomes with the parents.
Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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