Level: Foundational
Difficulty: Easy
Subtopic: Infant development
NCLEX: A 6-month-old infant at a well-child visit is being evaluated for developmental expectations for infant developme…
Psychology / lifespan development Health Promotion and Maintenance
Case Study
A 6-month-old infant at a well-child visit is being evaluated for developmental expectations for infant development. Assessment data include the infant does not sit with support and has poor head control. Which assessment approach should the nurse use first?
Question
A. Begin invasive procedures before any focused assessment.
B. Screen for instability, then perform a focused assessment related to the presenting concern.
C. Use only the chart from admission without current data.
D. Defer assessment until all medications are administered.
B. Screen for instability, then perform a focused assessment related to the presenting concern.
C. Use only the chart from admission without current data.
D. Defer assessment until all medications are administered.
Rationale
Correct answer: B. Screen for instability, then perform a focused assessment related to the presenting concern.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.