A nurse in a well-child clinic notes that a 5-month-old is not able to hold her head up.Which action by the nurse is the most appropriate?
A) Ask about other developmental milestones .
B) Document the finding in the child's chart.
C) Measure the child's head circumference.
D) Obtain the child's length and weight.

Question

Quizplus · Accepted Answer

Difficulty holding the head up by an appropriate age is a manifestation of hydrocephalus.Another sign of this disorder is an enlarging head,so the nurse measures the child's head and compares it to age-related norms.The other actions are appropriate,but not as specifically associated with hydrocephalus as measuring head circumference.

A Nurse in a Well-Child Clinic Notes That a 5-Month-Old