2024 PN NCLEX Questions Nursing Practice Question
While performing a physical assessment on a 6-month-old infant, the nurse observes head lag. Which of the following nursing actions should the nurse perform first?
Correct Answer: B
Rationale: Head lag in a 6-month-old infant can indicate potential developmental or neurological concerns, necessitating immediate evaluation. Notifying the physician ensures that the infant receives a thorough assessment and any necessary interventions.
Option A, while promoting muscle development, is not the immediate priority; addressing potential underlying issues takes precedence. Option C, documenting findings, is essential but should follow notifying the physician to ensure timely action. Option D may cause unnecessary alarm without a proper evaluation, and it is premature to speculate on developmental delays without further assessment.