NCLEX-RN · Question #380
A 9-month-old infant is being examined in the general pediatric clinic for a routine well-child checkup. His immunizations are up to date, and his mother reports that he has had no significant…
The correct answer is D. Significant head lag when raised to a sitting position. (A) This position is indicative of a possible meningeal irritation or infection such as meningitis. (B) This position is seen most frequently in infants who have had an injury to the sternocleidomastoid muscle. (C) Most infants aged 4 months and older are able to maintain this…
Question
A 9-month-old infant is being examined in the general pediatric clinic for a routine well-child checkup. His immunizations are up to date, and his mother reports that he has had no significant illnesses or injuries. Which of the following signs would lead the nurse to believe that he has had a cerebral injury?
Options
- AHyperextension of the neck with evidence of pain on flexion
- BHolding the head to one side and pointing the chin toward the other side
- CHolding the head erect and in the midline when in a vertical position
- DSignificant head lag when raised to a sitting position
How the community answered
(45 responses)- A4% (2)
- B11% (5)
- C2% (1)
- D82% (37)
Explanation
(A) This position is indicative of a possible meningeal irritation or infection such as meningitis. (B) This position is seen most frequently in infants who have had an injury to the sternocleidomastoid muscle. (C) Most infants aged 4 months and older are able to maintain this position. (D) Infants older than 6 months of age should not have significant head lag. This is a sign of cerebral injury and should be referred for further evaluation.
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