The nurse is assessing an 8-month-old infant for head lag, pulling the infant by the hands from a supine to a sitting position. The head does not stay in line with the body then being pulled forward
Which of the following statements best represents the significance of this finding? a. This is a normal finding, as the infant's head will not stay in line until after 8 months of age.
b. The nurse has not conducted the test correctly and must do it again using proper technique.
c. Significant head lag after the age of 6 months may indicate brain injury and needs further investigations.
d. Head lag should not be tested until the child is over 1 year of age.
C
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A Incorrect. Since the head does not stay in line with the body then being pulled forward into a sitting position, the nurse assesses that this is not normal.
B Incorrect. Pulling the infant by the hands from a supine to a sitting position is the correct means to test for head lag.
C Correct. Significant head lag indicates head control is not keeping pace with normal development, and after 6 months of age may indicate brain injury and should be further investigated.
D Incorrect. Testing for head lag should begin as early as 3 months, no later than 4 months.
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