Developmental Milestones in a Well 4-Month Old

Sarah, a healthy infant born at 40.5 weeks gestation after an uncomplicated pregnancy, is brought in for a four-month well child visit. Parents report the infant is feeding well, smiling frequently, and becoming more interactive with family members. 

Which of the following is most consistent with a normal developmental exam for an infant of this age?

A. Rolls back to abdomen and transfers objects hand to hand

B. brings hands together and laughs out loud

C. Lifts head briefly when prone and startles to loud sounds

D. Increase babbling and sits without support

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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: Sarah, a healthy infant born at 40.5 weeks gestation after an uncomplicated pregnancy, is brought in for a four-month well child visit. Parents report the infant is feeding well, smiling frequently, and becoming more interactive with family members. Which of the following is most consistent with a normal developmental exam for an infant of this age? 

A. Rolls back to abdomen and transfers objects hand to hand 

B. brings hands together and laughs out loud 

C. Lifts head briefly when prone and startles to loud sounds 

D. Increase babbling and sits without support

And the correct answer is B. Brings hands together and laughs aloud. Where do you start with a question like this? First, determine what kind of a question it is. We're being asked to see a younger infant and determine if developmental milestones are met. This would be an assessment question as you're looking at this little one as part of the overall evaluation during a well child visit.

What about developmental questions on the NP boards? Well, generally on the boards, they'll focus on questions on term infants who are well with no particular health issues. What I'm saying here is yes, these questions can be among some of the most challenging for family and adult-gero NPs because most of you have very little to no experience of  working with children. And even though you'll hear people say, "Oh, those ped developmental questions, they were the ones that really, really messed with me during the boards." Please keep in mind these are actually very low-level questions. Certainly, there is a range of exactly when kids meet a certain milestone, but the answer is fact-based. In other words, you and I cannot have a difference of opinion on what's a normative range for a child to be able to sit without support. It generally is ages 6 to 8 months, maybe as long as 9 months. That's it. We're not going to be saying, well, I think it's 3 months and you think it's a year. No, no, no, no. Then in that case, we'd both be wrong. So it's around 6 to 8 months maybe all the way up to 9 months. 

Consider this, normative neurodevelopment in early infancy starts from the top and moves its way down. Technical term for this is cephalocaudal progression. So head and neck control precedes trunk control. Trunk control precedes mobility. From a socialization and communication viewpoint, eye tracking precedes smile, smile precedes laugh, and all of this precedes babbling. 

In this question, you'll notice that each answer has two pieces of information in it. And both pieces of information must be factual for the answer to be correct. There's no partial correct answer credit on the NP boards. The other key is keep in mind what is term pregnancy. It ranges from 39 weeks to 40 weeks and 6 days. Hence, this baby was born at term. We're also told that the baby is well, in for a well child visit and that the parents have no particular concerns. Therefore, take it for what's being said here. This is a healthy little one. With this information in mind, let's take a look at the question and possible answers.

Sarah, a healthy infant born at 40.5 weeks gestation after an uncomplicated pregnancy, is brought in for a 4month well child visit. The parents report the infant is feeding well, smiling frequently, and becoming more interactive with family members. Which of the following is most consistent with a normal developmental exam for an infant of this age? 

A. rolls from back to stomach and transfers object hand to hand. This is incorrect in his example of a milestone that a child would likely not reach until about 6 to 8 months of age. 

B. brings hands together and laughs aloud. This is the correct answer. One way of thinking of this is bringing hands together is a precursor to being able to transfer objects hand to hand. And kind of the miraculous part of thinking of this is once the little one starts bringing their hands together and then graduates, if you will, to transferring objects hand to hand, the baby now appreciates that the two sides of the body are actually linked up to one another. Additional four month milestones include rolling tummy to back, which is easier to do than back to tummy, and reaches for objects. 

C. Lifts head briefly when prone and startles to loud sounds. This is a significantly earlier developmental milestone, usually achieved by age 6 weeks for the head lifting. Consider this, a baby at this age, at age four, likely has great head control. And that would be something that you would expect because the baby should be rolling, right? And while a four-month-old could react with some distress to a loud sound, um, usually with a marked startle reflex, that startle or also known as the moral reflex is actually starting to fade by four months. By the way, persistent presence of newborn reflexes. What you would want to consider is that the next step would be a referral to early intervention for uh facilitation of deeper assessment and initiation of appropriate therapy. 

D. increased babbling and sits without support. These are milestones that you would expect be in a little one between the ages of six to eight months old, maybe even six to nine months old. 

Key takeaway when looking at pediatric developmental questions, invariably you will have a milestone or two that the baby has already acquired or a milestone or two that is beyond the baby's given age. And keep that in mind. and that will allow you to help determine the best answer.

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.