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.   

Ariel is a 7-month-old infant, born at 40 weeks gestation, with Apgar scores of 9 and 10. The baby is up-to-date with well-child care and immunizations and has had two minor episodic illnesses at age 4 in 6 months with full recovery. Ariel rolled tummy to back, and started purposely bringing her hands together and babble at around age 4 months, and has had a social smile since age 2 months. Ariel is the youngest of three children, and today parents mention they're concerned that “She isn't sitting by herself yet. Our older kids were all sitting by now. She tries, but then she falls over.” Physical exam reveals a highly interactive, healthy-appearing infant with excellent muscle tone who age-appropriately resists the exam. The NP considers which of the following?

Refer the infant to an early intervention program for additional evaluation.
Discuss referral for genetic counseling with the child's parents.
Advise that the child's clinical presentation is consistent with normal parameters for an infant of this age.
Order testing for plumbism and iron deficiency anemia.

The correct answer is: C. Advise that the child's clinical presentation is consistent with normal parameters for an infant of this age.

Where do you start with a question like this? First, determine what kind of a question it is. Given we're provided with a good amount of information about the infant, and then asked what the next steps are, this is a diagnosis question. You might look at it and say, well, it doesn't feel much like a diagnosis question because where is the ICD-10 code buried in this question? But what we're being asked to do is comment on whether this child's development is within normal limit parameters or not, and that dictates what the next steps are.

Let's break this down. We're told that this is an infant who was born in a full-term pregnancy with great Apgar stores, and therefore we should apply normative age parameters for the little one's development.

We're also told that the child generally has been well since birth with a couple of episodic minor illnesses that have resolved. Given that she's the youngest of three kids, this is not at all alarming. Most younger children in a family pick up episodic illnesses from the older siblings. Additional important information is that the child is up-to-date with well-child care, as well as immunizations.

Keep in mind, and I've said this in so many podcasts before, every single piece of information within the question is important. The story, or the narrative of the question, will really help guide you. If this child's had a major developmental issue, likely this would have been picked up by the time the child was 7 months old, because of course the child would have been seen a number of different times.

But we're being given information that the child started babbling at around the right age, as well as rolling tummy to back and purposely putting hands together, again at a non-target age. And developmental concerns with this child? No big red flags are shown here.

She's the youngest of three kids and every single child develops at their own pace. It's not at all uncommon to hear something like this from parents or caregivers who have experience with other children. They'll voice concerns such as, oh, the oldest started to walk at 11 months, but the second one didn't start walking till 15 months. And what our role is as PCPs is to say, both of those parameters: perfectly, perfectly normal. It's not that one child was particularly precocious or the other one was particularly behind. But again, development in healthy children occurs within a wide variety of parameters. With that in mind, let's take a look at the options in the question. And yes, you do need to have committed to your knowledge base some of the major developmental milestones that children achieve.

Ariel is a well 7-month-old infant born at 40 weeks gestation with Apgar scores of 9 and 10. The baby is up-to-date for well-child care and immunizations, and has had two minor episodic illnesses at ages 4 and 6 months with full recovery. Ariel rolled tummy to back, started to purposely bring hands together and babble at around age 4 months, and has had a social smile since age 2 months. Ariel is the youngest of three children, and today the parents mention that they're concerned that, “She's not sitting up by herself yet. Our older kids were all sitting by now. She tries, but then she falls over.” Physical exam reveals a highly interactive, healthy appearing infant with excellent muscle tone who age-appropriately resists the exam. The NP considers which of the following?

And before I get into the answers, one of the things that I want to say is this comment on age appropriately resists the exam. That's actually a really important part of documenting normal neurological function in little ones who are pre-verbal because even as young as 7 months, sometimes they just don't want you looking at their ears and they will develop the strength of ten adults to push you away. But that's all perfectly, perfectly normal, and I always include it in my clinical note.

So back to the question the NP considers which the following?

Refer the infant to an early intervention program for additional evaluation. This is, of course, incorrect. Healthy term infants generally start to sit solo between ages 6 and 8 months, and we're told here she's 7 months old. She keeps trying to sit, but then she falls over. She's certainly within normal limit parameter for starting to sit solo. A good next step will be to have the parents contact the practice if the child is still not sitting solo in two more months.
Discuss referral to genetic counseling with the child's parents. This is also not correct. There's nothing in this scenario to raise red flags about genetic concerns with this child.

Advise the child's clinical presentation is consistent with normal parameters for an infant of this age. Option C, of course, as I've already mentioned, is the correct answer. This is a well-child from a term pregnancy who will likely start sitting solo between the ages of 6 to 8 months of age. Children do go through a period of time of attempting to sit solo and then they often fall over, and they really seem quite unfazed by this. I always look at them and think, it looks like they just kind of hold themselves up for a little while, run out of steam, and then topple over, and they don't cry. They don't seem terribly upset by it. And really what they're showing you is their neurological and skeletal muscle development. It's just not quite there yet. But boy, they were going to work on it. And you might have seen this with kids who are just starting to walk, is first they look a little bit like they're walking on the deck of a ship. You know, they're all over the place, hobbling back and forth, but giving it their very, very best. And then they fall down. And again, they seem unfazed by it. But what they're doing is they're literally learning to walk. And what Arielle is now doing is she's learning how to sit. She's giving it a try, but she's just neurologically and skeletal muscle development-wise, just not quite there yet. That's okay. That's okay. We're told as well that this child has good muscle tone and age appropriately resists the exam. We would expect both of those. A few other developmental milestones have been on target with this child. The best intervention here would be to tell the parents is just give a call for reevaluation, particularly if she's still not sitting solo by the time she's 9 to 10 months old. And I swear, what happens with babies like this who have a little bit different timeline than their older siblings is that within a week of the parents voicing the concern, all of a sudden this child is sitting up solo like she's been sitting up her entire life. They'll all of a sudden kind of put together. And if you're in contact with the parent, even a couple of weeks later, they'll go, yeah, she's fine. She's sitting solo now.

Last option was D. Order testing for plumbism and iron deficiency anemia. Obviously, this isn't the correct answer. At the same time, you might get a question like this on boards that gives you a lab test or some other parameter that's relatively easy to measure.

Coming from the R.N. role, I'm sure you're accustomed to having lab data to look at tests to interpret, etc. In pediatrics, what do we do? We do so much of our work with simply looking at the totality of the child, not depending on diagnostic studies. And the totality of the child here is term pregnancy, excellent Apgars, other major development milestones on target. And then the child is attempting to achieve another developmental milestone, sitting solo, just isn't quite there yet. This is a perfect example, and we're not going to order any diagnostics.

Key takeaway: Developmental assessment is an important part of well-child care. Discussing the variations within what are acceptable parameters is a critical part of your ongoing dialog in partnership with children and their parents and caregivers. Indeed, this is one of my favorite parts of family practice, and a role I feel incredibly privileged to provide. And just one other personal comment here. I have been honored to have kids who grew up where I was their primary care provider their entire lives, and then when they had children, they brought their kids from me to provide their offspring’s primary care. How honored I feel when this happens.

Thank you for listening to NP Certification Q&A presented by Fitzgerald Health Education Associates. Please rate, review, and subscribe to this podcast. And for more NP resources, visit FHEA.com  