Question

A 4-month-old, full-term infant is seen in the well-child clinic. The nurse is most concerned when which finding is observed?

a. The infant's head turns to the side when a sound is made at the level of the ear
b. The infant's head lags when pulled from a lying to a sitting position
c. The infant is drooling
d. The infant does not focus on a toy held close to the face

Answer 1

The nurse would be most concerned if a 4-month-old infant does not focus on a toy held close to the face, as this could indicate developmental delays or vision issues.

Step-by-step explanation:

The nurse would be most concerned if a 4-month-old full-term infant does not focus on a toy held close to the face. By four months of age, healthy infants should be able to follow objects with their eyes, and a lack of eye focus may suggest developmental delays or vision problems. Points (a) "The infant's head turns to the side when a sound is made at the level of the ear," (b) "The infant's head lags when pulled from a lying to a sitting position," and (c) "The infant is drooling" are considered normal for this age. Head turning to sound indicates normal hearing and reflexes, head lag is expected as they are still developing neck strength, and drooling is also typical since drool production often increases at this age, potentially due to beginning stages of teething.