At a 4-year-old well-child visit, the nurse notes the child's immunization record shows vaccines given only through the 18-month visit. The parent reports the child recently stopped playing pretend games and no longer draws a person with several body parts, skills he demonstrated last year, though he can catch a large ball. The child currently rides in a forward-facing car seat with a harness and can sit independently without support. Which nursing actions are appropriate at this visit? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
At the 4-year well-child visit, the documented immunization gap requires catch-up planning (Choice 1), and loss of previously mastered pretend play and drawing skills requires prompt developmental follow-up (Choice 2). The child should remain in the forward-facing harness until its height or weight limit is reached and then use a belt-positioning booster (Choice 6). Stacking four blocks is an earlier milestone and does not establish age-appropriate fine-motor development (Choice 3). Lack of recent illness does not remove the need for catch-up immunization (Choice 4), and sitting independently is not the criterion for leaving a harnessed seat (Choice 5).
Clinical Reasoning At the 4-year well-child visit, the documented immunization gap requires catch-up planning (Choice 1), and loss of previously mastered pretend play and drawing skills requires prompt developmental follow-up (Choice 2). The child should remain in the forward-facing harness until its height or weight limit is reached and then use a belt-positioning booster (Choice 6). Stacking four blocks is an earlier milestone and does not establish age-appropriate fine-motor development (Choice 3). Lack of recent illness does not remove the need for catch-up immunization (Choice 4), and sitting independently is not the criterion for leaving a harnessed seat (Choice 5).
Option Review
Correct — The vaccination record shows no immunizations since 18 months, so the nurse should notify the provider so catch-up vaccines appropriate for a 4-year-old can be ordered without delay.
Correct — Loss of previously mastered skills such as pretend play and drawing a person with several parts is a red flag for regression and warrants referral for developmental evaluation now rather than watchful waiting.
Incorrect — Stacking four blocks reflects an earlier fine-motor milestone typically achieved well before age four, so this finding does not confirm that the child's current fine-motor skills are age-appropriate.
Incorrect — Absence of illness symptoms does not eliminate the need for catch-up immunizations; the documented gap since the 18-month visit still requires the provider to order missed vaccines.
Incorrect — Sitting independently and unsupported is not the criterion for discontinuing a harnessed car seat; that decision depends on the child's height and weight meeting the seat's forward-facing limits.
Correct — A 4-year-old should remain in a forward-facing harness until the child reaches that seat's height or weight limit, then transition to a belt-positioning booster until the vehicle belt fits properly.
Sources
12026 NCLEX-RN Test Plan
2CDC: Milestones by 4 years
3CDC: Recommended vaccines for children
A 4-year-old is brought for a well-child visit; immunizations are documented only through the 18-month visit, and the parent describes loss of previously acquired play and drawing skills alongside continued gross-motor ability and independent sitting in a forward-facing harnessed car seat.