CCRN Critical Care Nursing

Category - Neonatal

A nurse is assessing a 6-month-old infant during a routine well-baby check up. Observing which of the following symptoms should alert the nurse to refer the child for further evaluation?
  1. Infant speaks single consonants
  2. Present Moro’s embrace reflex
  3. Infant rolls from front to back and back to front
  4. Absent tonic neck reflex
Explanation
Answer - B - Moro’s embrace reflex should not be observed at 6 months of age; therefore, further evaluation is necessary. A 6-month-old child can speak in single consonants and roll over both ways. Tonic neck reflex disappears at 4 months.
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