The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?

Choice A rationale The startle reflex, also known as the Moro reflex, is a normal response in newborns but typically disappears around 4 to 6 months of age. If a 6-month-old infant still demonstrates this reflex, it may indicate neurological issues that require further evaluation. Choice B rationale Playing “peek-a-boo” is a normal developmental milestone for a 6-month-old infant. It shows that the infant is starting to understand object permanence, which is the understanding that objects continue to exist even when they cannot be seen. Choice C rationale Doubling birth weight by 6 months is a normal growth milestone for infants. This indicates that the infant is growing and developing as expected. Choice D rationale Turning the head to locate sound is a normal developmental milestone for a 6-month-old infant. This shows that the infant’s hearing and neck muscles are developing appropriately.