# Situation: A public health nurse works with the barangay nutrition scholars (BNS) and barangay health workers (BHWs) of an upland barangay on its nutrition program, including the yearly Operation Timbang Plus (OPT Plus). A BHW shows the nurse the weight record of a 10-month-old girl. Her weight-for-age was about −1 z at 6 months. Her weight has stayed the same for the last 3 monthly weighings, and she is now at −1.8 z. What does this finding MOST likely indicate?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=627254  
> language: ko  
> subject: Nursing Practice I — Community Health Nursing

## 문제

Situation: A public health nurse works with the barangay nutrition scholars (BNS) and barangay health workers (BHWs) of an upland barangay on its nutrition program, including the yearly Operation Timbang Plus (OPT Plus).

A BHW shows the nurse the weight record of a 10-month-old girl. Her weight-for-age was about −1 z at 6 months. Her weight has stayed the same for the last 3 monthly weighings, and she is now at −1.8 z. What does this finding MOST likely indicate?

## 보기

1. Stunting from long-term undernutrition since birth
2. Underweight that needs enrollment in supplementary feeding
3. Normal growth, because her weight is still above −2 z
4. Growth faltering needing a feeding and illness assessment **✔ 정답**

**정답: 4**

## 해설

A flat or falling growth curve is an early warning sign, even before the child crosses a cutoff. The girl's weight has not increased for 3 months, so her position has dropped from about −1 z to −1.8 z. The nurse should assess feeding and recent illness and counsel the mother before she becomes underweight.

## 심화 해설

Clinical context

In OPT Plus, the weight-for-age z-score (WAZ) is not interpreted only at a single cutoff such as −2. A child whose WAZ is still above −2 can still be in trouble if the growth curve is flattening or falling, because the trajectory matters as much as the current number.

What the record shows

At 6 months the girl was around −1 z. Over the next 3 monthly weighings her weight did not increase, so her position dropped to −1.8 z. This is not yet underweight by the conventional cutoff, but it is a clear change in the pattern of growth.

Why this is growth faltering

A flat or downward WFA curve is an early warning sign that appears before a child crosses the −2 z threshold. Growth monitoring is designed to detect this kind of deceleration early, because waiting until the child is already underweight delays intervention. In this case, no weight gain for 3 consecutive months means the child is not following her previous growth channel.

Watch out! A WAZ of −1.8 is still above −2, but the change from −1 to −1.8 over 3 months is the abnormal finding. Do not classify this as normal growth just because the cutoff has not been crossed.

Why stunting is not the best answer

Stunting reflects linear growth failure, measured by length-for-age or height-for-age z-score (LAZ/HAZ), not weight-for-age alone. A low WAZ can occur with acute undernutrition, recent illness, or inadequate intake, while stunting develops over a longer period and requires length measurement. The data provided do not include length, so stunting cannot be concluded from WAZ alone.

Why supplementary feeding alone is premature

Supplementary feeding may eventually be needed, but the immediate priority is to find out why the weight has plateaued. The child needs a feeding assessment and an illness review before the nurse decides on an intervention. Enrolling the child directly into a feeding program without assessing the cause would skip the diagnostic step.

Applying the evidence to this child

Growth faltering on the WFA curve is recognized as an early indicator of risk for more severe malnutrition. Automated interpretation of WFA growth curves has been proposed precisely because simple weight changes or a single z-score can miss children whose growth is decelerating. The key signal here is the slope of the curve, not the absolute z-score at one point.

The appropriate response is to assess feeding adequacy, frequency, and technique, and to ask about recent illnesses such as diarrhea, fever, respiratory infection, or any condition that could reduce intake or increase losses. The goal is to identify and correct the cause before the child becomes underweight. This aligns with the public health nurse’s role in OPT Plus: growth monitoring is a screening activity that must be followed by assessment and counseling when a child’s growth pattern deteriorates.

Key point! A change in z-score over time is more informative than a single measurement. A drop from −1 to −1.8 without weight gain for 3 months indicates growth faltering, even though the child is not yet below −2.

## 임상 시나리오

Growth Faltering Detection in OPT PlusAct on trajectory, not just the cutoff
A flat or falling weight-for-age curve is an early warning sign, even when the z-score is still above -2. A drop from -1 z to -1.8 z over 3 months with no weight gain indicates growth faltering.

Immediate steps: assess feeding practices and recent illness, counsel the mother, and monitor closely before the child crosses the -2 z underweight threshold.

CautionDo not classify growth as normal just because the z-score is above -2. The change in trajectory over time is the abnormal finding that requires intervention.

## 핵심 개념

- **Growth faltering** — A flattening or downward trend in growth indicators over time, signaling risk before a child crosses a cutoff such as -2 z.
- **Weight-for-age z-score (WAZ)** — A measure of a child's weight relative to age, used in growth monitoring to detect undernutrition risk.
- **OPT Plus** — Operation Timbang Plus, an annual growth monitoring and nutrition screening program for children in the Philippines.
- **Stunting** — Linear growth failure measured by length/height-for-age z-score, reflecting long-term undernutrition.
- **Underweight** — Weight-for-age below -2 z, indicating acute or chronic undernutrition requiring intervention.

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