# 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. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=558427&lang=en > language: en > subject: Developmental Stages and Transitions > category: HPM ## Question 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. 1 Notify the provider that catch-up vaccinations are due based on the gap since the child's 18-month visit. 2 Refer the child for developmental follow-up because he has stopped engaging in pretend play and no longer draws a person with several body parts, skills he previously demonstrated. 3 Document that the child's fine-motor skills are age-appropriate because he can stack four blocks into a tower. 4 Tell the parent that additional vaccines are not needed right now since the child has not shown any illness symptoms since the last visit. 5 Advise the parent that the child can transition out of a forward-facing car seat with a harness now that he can sit independently and unsupported in a regular seat. 6 Reinforce that the child should remain in the forward-facing harness until reaching the seat's height or weight limit, then use a belt-positioning booster. ## 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). ## In-depth explanation Correct Answer Choices 1, 2, 6 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 ## Clinical scenario 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. ## Related questions - [A nurse is conducting an annual well-adolescent visit for a 15-year-old client per AAP Bri…](https://mymerci.kr/pages/nclex_q.php?qn_id=366228&lang=en) - [Review the toddler's developmental surveillance timeline and determine the appropriate scr…](https://mymerci.kr/pages/nclex_q.php?qn_id=395206&lang=en) - [A client has repeated injuries and the partner answers all questions. Which nursing action…](https://mymerci.kr/pages/nclex_q.php?qn_id=397290&lang=en) - [A 57-year-old client asks about shingles vaccination. Which teaching should the nurse prov…](https://mymerci.kr/pages/nclex_q.php?qn_id=397346&lang=en) - [Review the infant's developmental timeline and determine the most appropriate nursing resp…](https://mymerci.kr/pages/nclex_q.php?qn_id=547004&lang=en) - [A nurse is planning therapeutic play activities for three hospitalized children. Match eac…](https://mymerci.kr/pages/nclex_q.php?qn_id=568379&lang=en) - [A pediatric nurse must select the highest indicated next action for each independent visit…](https://mymerci.kr/pages/nclex_q.php?qn_id=569392&lang=en) ## Read in another language - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=558427&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=558427&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=558427&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=558427&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=558427&lang=vi) --- More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en) _For study reference only. Always follow current clinical guidelines and your institution’s protocols._