Infant Development Question

A healthy seven‑month‑old boy presents with his parents for a well‑child visit. He was born at 39.5 weeks gestation via spontaneous vaginal delivery. After a pregnancy without complication, he and his mother went home after 24 hours. He is primarily breastfed with a small amount of solids and continues to be at the 50th percentile weight and 40th percentile length. The parents voice no concerns. 

Which of the following is the most appropriate developmental milestone for this child's age?

A. sits briefly with support

B. is able to pull to stand

C. rolls front to back

D. uses pincher grasp to pick up a small object

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Transcript

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 healthy 7-month-old boy presents with his parents for a well-child visit. He was born at 39.5 weeks gestation via spontaneous vaginal delivery after a pregnancy without complication. He and his mother went home after 24 hours. He is primarily breastfed with a small amount of solids and continues to be at the 50th percentile weight and 40th percentile length. The parents voiced no concerns. Which of the following is the most appropriate developmental milestone for this child's age?

A. Sits briefly with support

B. Is able to pull to stand

C. Rolls front to back

D. Uses pincher grasp to pick up a small object. 

The correct answer is A. Sits briefly with support. 

How should you start with this question? First, as we've done with others, determine what kind of a question this is. Since we're gathering data about this baby, this is an assessment question. A bit of background information. I find that with my decades of teaching NP review, as they're getting ready for their boards, few topics strike more terror and the heart of the family nurse practitioner board candidate than pediatric developmental issues. I think part of this is because it feels different from what you've come from into the FNP role because typically you have no experience or very little experience with kids from your RN role. Well, some of you will come to boards with some PD experience. And if you do have peds experience, it's from urgent care or the emergency department where you're not seeing kids when they're well. But well-child care is a critically important part of the family nurse practitioner's role as a primary care provider. 

Upwards to 20% of the FNP exam is focused on pediatrics. And out of that 20% there'll be a tiny tiny tiny bit of questions on OB like super small maybe five or six questions on childbearing. 

One of the most important health care activities for children is in fact the well child visit. It's an incredibly important interaction between the family and including the child and the health care provider when the little one is not sick. Why do we do PD well-child visits? Well, they're designed to promote optimal growth and development, prevent disease, and identify problems early through routine surveillance, screening, immunization, and anticipatory guidance. 

But let's go back to the question. Do you have to memorize a myriad of pediatric developmental milestones? Actually, no. There are a few key milestones that often come up on the boards because these are surrogate markers for the child being on target developmentally. Now, as I say this, remember, and I believe this to my core, every child is unique. Some kids achieve milestones earlier than others, some later. And pediatric milestones are generally thought to be within a range of time rather than an absolute date. And rather than go through a number of PD milestones, what I want you to do is take this question, break it down so that if you get a question like this on boards, you'll be able to think this through. 

And I'm going to make one more comment about this. There are questions on the boards that I call panic questions. Like the NP board candidate will read the seven-month-old and then panic, panic strikes. Okay, that's all you've read. It's a seven-month-old and you can get into a downward spiral of thinking. I know nothing about kids. I can't possibly answer this question. If I can't answer this question, I can't answer any other questions on the boards. And it really is a big issue. So, please, what you want to do, you see that the question is about a child, deep breath, break the question down, and I'll be willing to bet you're going to get the answer correct. 

All right. So, let's go back take another look at the question. And remember, I'm going to do a major breakdown of the question so that you know how to proceed when you hit a question like this on boards. A healthy seven-month-old presents with his parents for a well-child visit. It says the baby's healthy without acute or chronic health problems. Believe it. If it says the baby's healthy, leave it be. Leave it be. He was born at 39.5 weeks gestation. via spontaneous vaginal delivery after a pregnancy without complication. So, this describes a full-term pregnancy which is defined as 39 weeks 0 days to 40 weeks 6 days in duration. We're told there were no health problems during the pregnancy. The stage is set that we should expect typical pediatric developmental milestones. So, keep in mind for the little squirts who are born pre-term prior to 37 weeks’ gestation, developmental milestones are adjusted. I'll get into that in another peds Q&A. 

He and his mom went home after 24 hours. This tells me that mom had no significant post birth complications and that the baby also did really well in that first day of life. There is a woman who I follow on maybe Instagram. I think I think it's Instagram. Anyway, Jen Hamilton, she's pretty well known in the labor and delivery room world and she is an RN and she talks about babies making the transition from intrauterine life to extrauterine life as the transition from an indoor cat to an outdoor cat. And I always think about that when I see a little one and goes, "Oh, this baby has turned into a wonderful little outdoor cat and has made that transition beautifully." As you say, you might be thinking, "Oh, you're reading too much into the question, Dr. Fitzgerald." No, no, no, no, no, no. I'm not reading too much into the question. I'm simply interpreting information that is given and I'm comparing that to what I know about a healthy complication free birth and early postpartum period for the mom and what I know about the newborns who are similarly transitioning appropriately to extra uterine life. And when you think about it, when you think about it, every birth is truly a miracle. It really is. 

He's primarily breastfed with a small amount of solids and continues to be at 50th percentile weight and 40th percentile length. Well, I in real life, I want to know more about his diet, how is breastfeeding going, etc. But it's very reassuring. It sounds like he's been on the same growth curve for a while. We're told 50th percentile for weight, 40th percentile for length. Weight and length don't always land in the exact same percentiles, but it sounds like this little one is doing pretty well nutritionally and growth wise. The parents voice no concerns. Well, this statement stands for itself. The parents are viewing their baby as doing well, and from what I could see, it does seem like this little squirt is thriving. Please recall with well child visits, being a parent is very hard work. Praise for what's going well is an important part of the pediatric well-child visit. 

Now, we're going to go back to the purpose of the question. Which of the following is the most appropriate developmental milestone for a child of this age? A. Sits briefly with support. This is the correct answer. Term infants typically start sitting without support, usually between 6 to 8 months of age. For a few more details on the little squirts at this age, aside from sitting without support, even if it's briefly, even if it's briefly, it counts. Other things they do is they transfer objects hand-to-hand. The amazing part is once a little one takes an object, puts it from one hand to another, then brings it back again, that is the first time the baby recognizes that the two sides of their bodies are hooked together. It is fascinating to watch them do this. They typically will respond to name, and they begin to babble with like ba ba ba da da da or something along those lines. Depending on what language the child is hearing at whole at home, they will make different sounds. They will make different sounds, and I've been privileged to hear that in the exam room. 

Okay, so A is a best answer. B. Able to pull to stand. This is incorrect. This is a milestone that's usually more like 9 to 12 month range. One way to remember this is that the child is getting ready to walk and this is the first step in that process. So, you wouldn't expect a six-month-old, seven-month-old to be walking yet. Some kids are exceptional and they start pulled to stand really early, but most will be 9 to 12 months range. 

Rolls front to back. Now, this answer presents a bit of a conundrum, but gets to the issue of it's not the best answer. Term infants usually start rolling front to back around 6 months of age. So, we would certainly expect the seven-month-old to be able to do this. Indeed, the seven-month-old is probably able to row roll front to back and then back to front with great ease. This is also around the time that scheduled tummy time tends to go away because the baby is doing their own tummy time. They're rolling all over the place. So, why isn't this the correct answer? Because it is not the most recently achieved developmental milestone. So, this is another way of looking at it. We would expect all seven months old to roll from front to back. We would expect most seven-month-olds to be sitting without support. So always with the pedi development questions, look for the most recently achieved developmental milestone. 

And D. Uses pincher grasp to pick up a small object. This is incorrect. Pincher grasp is a fine motor skill that's usually achieved between the ages of 9 to 12 months in a term infant. 

Very brief summary then of well of pediatric developmental milestones in a well-term infant. At four month they roll. 6 months they sit. 9 months they pull to stand. 12 months pincher grasp.

Key takeaway. Keep in mind a few major pedi developmental milestones. This is going to help you with your NP board success. And I just have to say this, providing pediatric well-child care is one of the greatest privileges of being a family focused primary care provider. 

Voiceover: 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.