Pediatric ATI Practice Exam

Which finding during a well-child visit for a 5-month-old infant should the nurse report to the provider?

1. Head lags when pulled from a lying to a sitting position

2. Absence of startle and crawl reflexes

3. Inability to pick up a rattle after dropping it

4. Rolls from back to side

The correct answer is: Head lags when pulled from a lying to a sitting position

The appropriate finding to report is indicated by the observation of head lag when the infant is pulled from a lying to a sitting position. At 5 months old, infants typically have developed some head and neck control. They should be able to hold their head up steadily when pulled to a sitting position, indicating that they have achieved an important milestone in their motor development. Persistent head lag may suggest developmental delays or neurological concerns that warrant further evaluation by the healthcare provider. In contrast, the absence of the startle reflex, while noteworthy, is generally not as critical at this stage, as this reflex typically diminishes between 3 to 6 months. The inability to pick up a rattle after dropping it may also not raise immediate concern because fine motor skills are still developing, and infants around this age are practicing grasping and releasing. Lastly, rolling from back to side is a developmental milestone that some infants may achieve around this time, making it a normal finding rather than a cause for concern. Thus, the presence of head lag is the most concerning indicator at this age.