The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?
Explanation & Rationale
A. Demonstrates startle reflex: The startle reflex (Moro reflex) typically disappears around 3-4 months of age. If a 6-month-old still demonstrates this reflex, it may indicate a developmental delay or neurological issue, requiring further evaluation.B. Has doubled birth weight: Doubling of birth weight by 6 months is a normal developmental milestone. This response does not require further evaluation as it indicates appropriate growth.C. Turns head to locate sound: Turning the head to locate sounds is expected at this age and demonstrates normal auditory and neurological development. This response does not require further evaluation.D. Plays "peek a boo": Playing "peek a boo" is a typical social interaction for a 6-month-old and indicates normal social and cognitive development. This response does not require further evaluation.