12 個月大嬰兒的哪項評估發現需要護理師立即追蹤？
Which assessment finding in a 12-month-old infant requires immediate follow-up by the nurse?
- AThe infant cannot stand while holding onto furniture嬰兒扶著家具站立
- BThe infant cries when separated from the primary caregiver嬰兒與主要照顧者分開時哭泣
- CThe infant has not yet developed a pincer grasp✓ 正解嬰兒尚未發展出鉗狀抓握
- DThe infant's birth weight has tripled嬰兒體重已達出生時的三倍
這題考查 12 個月大嬰兒發展的精細程度與警訊。正確答案 C（尚未發展出鉗狀抓握）是顯著的遲緩信號。鉗狀抓握（Pincer grasp，用拇指和食指指尖捏物）通常在 8-10 個月出現，12 個月應已成熟。若未出現，可能暗示細微動作或神經發展異常。選項 D（體重增加三倍）是 1 歲嬰兒的正常生理預期。選項 A（無法扶物站立）雖需關注，但通常 12 個月才開始嘗試獨自站立或放手走，扶站通常在 9-10 個月，若 12 個月完全無法扶站也需要追蹤，但 C 的精細動作缺失在神經評估中更具指標性。選項 B（分離焦慮）是此年齡層的正常社會心理表現。臨床上，護理師應警覺發展的「紅旗」，及早介入以優化預後。
This question tests knowledge of fine-motor milestones and warning signs in a 12-month-old. The correct answer is C (the absence of a pincer grasp), which is a significant developmental red flag. The pincer grasp (picking up an object using the tips of the thumb and index finger) typically develops between 8 and 10 months and should be mature by 12 months. Its absence may suggest fine motor or neurological developmental abnormalities. Option D (tripling birth weight) is a normal physiologic expectation at 1 year. Option A (inability to pull to stand) warrants attention since pulling to stand typically occurs at 9-10 months, with independent standing or cruising emerging around 12 months; complete inability at 12 months also requires follow-up, but the absence of a fine-motor skill in C is more clinically indicative on neurological assessment. Option B (separation anxiety) is a normal psychosocial finding at this age. Clinically, the nurse should be alert to developmental red flags and intervene early to optimize outcomes.
美國 NCLEX 非常強調「Red Flags」的識別；台灣臨床實務中，家長常因過度保護或「大雞晚啼」觀念而忽略精細動作遲緩。護理師需運用標準化量表進行客觀溝通。