A nurse assesses a 4-month-old infant and notes the baby does not follow a moving object with her eyes. What action by the nurse is best?
a. Document the findings and continue the assessment.
b. Refer the child and parent to a pediatric neurologist.
c. Assess the child for other age-appropriate behaviors.
d. Assess the child for signs of child abuse or neglect.
ANS: C
A 3-month-old child should be able to follow a moving object with his or her eyes. However, one single abnormal assessment finding does not necessarily mean that the child has a growth and developmental delay. The nurse should assess for other age-appropriate behaviors. Documentation should occur but is not the priority action at this point. A referral is not warranted nor is assessing for child abuse based on the data.
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