Voiceover: Welcome to NP Certification Q&A Presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.
Margaret Fitzgerald: A six-month two-week infant who was born at 40.5 weeks gestation after an uneventful pregnancy is brought in for a well child visit. The parents mention, "His older sister was a really different baby. I think he's not quite where she was in his development at this age." Which of the following would not be a red flag requiring further evaluation?
A. Inability to roll in either direction.
B. Unable to transfer objects hand to hand.
C. Reaches for objects with one hand.
D. Ability to sit briefly without support.
The correct answer is A. Inability to roll in either direction.
Where should you start with this question? First, determine what kind of a question this is. And this is an assessment question where you are assessing pediatric development as part of a comprehensive well child visit.
A bit of background information. It's quite common for parents and caregivers to compare one child to another. In fact, I think it's just part of human nature. What you can end up with is parents and caregivers who have concern about a child who's just going a slightly different developmental path than an older or younger sibling. Certainly, part of our role as health care providers is to ensure there are no alarm findings. At the same time, milestones in pediatrics generally are not rigid. An example of that would be for somebody to say, "Oh, all kids must be walking by age 12 months or there's a problem." Well, actually the range for walking in kids is around depending on whose work you look at 11 to 12 months for a start all the way up to 15 or 16 months. Certainly, there are going to be some outliers where you'll see these little squirts who are walking at 8 to 9 months of age. That doesn't mean something is wrong with a 15-month old walker. It's just that child needed a little extra time to achieve that important milestone.
Reflecting on raising kids myself, neither one of my kids walked till they were about 15 months old. They walk very well as adults. In fact, both of them are long-distance runners.
Here we have a question about picking up a red flag on a younger child's development. And this child, what would be the issues that would trigger a discussion with parents or caregivers and warrant referral for additional assessment? Let's take a few minutes and go over some of the more common red flags in an otherwise term infant. Persistent head lag after 4 months. Remember, usually generally by the time the kids are 2 to four months, they've developed reasonable head and neck control. No social smile by four months. That's quite concerning and you would be thinking perhaps it could even be a problem with hearing or vision or some other global issue. No babbling or vocalization by 6 months. Lack of response to sound. That's a concern starting at birth because again you wonder whether this is a little one who can hear. Abnormal muscle tone, either mark stiffness or low tone. Again, that would be a concern that's investigated quite early on. I'm fully aware that healthy newborns can be a little on the floppy side, but they do start gaining some tone even in that first month of life.
With that information in mind, let's take another look at the question.
A six-month, two-week old infant who was born at 40.5 weeks gestation after an uneventful pregnancy is brought in for a well child visit. His parents mentioned his older sister was a really different baby. I think he's not quite where she was in his development at this age.” Which of the following findings would not be a red flag requiring further evaluation?
A. Inability to roll in either direction. This is the correct answer. And remember that kids will be able to for the most part roll in either direction by the time they're 6 months old. So, tummy to back, the range is typically, four to 6 months. Back to tummy 4 to 7 months. And you might say, "Yes, but this baby's only 6 and 1/2 months old." The fact that the baby's not rolling in either direction is of concern. Certainly, to do a little watch and wait or give him another month or so to achieve this milestone likely would be appropriate if the little one is reaching all the other 5 to 7-month old milestones. But the fact that he's missing that milestone that he should have had by age four months, the tummy to back is really of great concern. The other part of it is usually once kids figure out how to roll. They love rolling and they will do anything they can to show off their new skill. And so not rolling in either direction is a motor red flag. The next step would be referral to early intervention to facilitate deeper assessment and initiate appropriate therapy.
B. Unable to transfer an object hand to hand. Well, many kids when they're just 6 months old like this little one is can transfer objects hand to hand, but the normative range is 5 months to 7 months. He's not quite 7 months old yet. again with an otherwise reassuring exam. Give them another month or so to reach this milestone. Perfectly reasonable.
C. Reaches for objects with one hand. Kids start to reach for objects with one hand around 45 months of age and with two hands about 6 months plus. This is a good example of a milestone he would likely already have achieved and is not a developmental red flag.
D. Ability to sit briefly with support. The range on sitting briefly with support is four to six months of age and to sit solo 6 to eight months of age. This actually would represent normal development and would not be a developmental red flag.
Key takeaway. One of the most important parts of a well child visit is monitoring for developmental red flags. General rule, the next step is referral to early intervention to facilitate deeper assessment and initiate appropriate therapy.
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