A nurse in a well-child clinic notes that a 5-month-old is not able to hold her head up. Which action by the nurse is the most appropriate?
A.
Ask about other developmental milestones .
B.
Document the finding in the child's chart.
C.
Measure the child's head circumference.
D.
Obtain the child's length and weight.
ANS: C
Difficulty holding the head up by an appropriate age is a manifestation of hydrocephalus. Another sign of this disorder is an enlarging head, so the nurse measures the child's head and compares it to age-related norms. The other actions are appropriate, but not as specifically associated with hydrocephalus as measuring head circumference.
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