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
The correct answer is Choice A.Choice A rationaleThe presence of the Doll’s eye reflex (oculocephalic reflex) beyond the newborn period is abnormal and should be reported. This reflex should disappear by 2-3 months of age. Its persistence may indicate neurological issues.Choice B rationaleNo head lag when pulled to a sitting position is a normal finding in a 4-month-old infant. By this age, infants typically have developed enough neck muscle strength to hold their head steady.Choice C rationaleThe presence of tears when crying is a normal finding in a 4-month-old infant. Tear production usually begins around 2-3 months of age.Choice D rationaleA positive Babinski reflex is normal in infants up to 2 years old. It is an expected finding and does not require notification to the provider.