ATI RN Paediatrics Nursing Proctored Exam 2023
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?
Explanation & Rationale
A. The Babinski reflex is normal in infants up to 12-18 months and does not require intervention. B. The presence of tears when crying is a normal finding and does not indicate a concern. C. The doll’s eye reflex (oculocephalic reflex) is normally present in newborns but disappears by 2 months of age. Its presence in a 4-month-old is abnormal and may indicate neurologic dysfunction, such as brainstem injury or increased intracranial pressure. This warrants immediate notification of the provider. D. By 4 months, infants should have good head control with minimal or no head lag, which is normal.
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