Infancy: Birth to 1 Year Practice Questions

66 multiple-choice questions on Infancy: birth to 1 year for paramedic and EMT students, from Chapter 10 (Life Span Development). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

66 practice questions

1. The normal heart rate range for a newborn is approximately:

   1. A. 40 to 80 beats/min
   2. B. 60 to 100 beats/min
   3. C. 80 to 120 beats/min
   4. D. 100 to 180 beats/min
   Show answer

   Answer: D. 100 to 180 beats/min

   Rates slow gradually through the first year.

2. The normal respiratory rate for a newborn is approximately:

   1. A. 12 to 20 breaths/min
   2. B. 20 to 30 breaths/min
   3. C. 30 to 60 breaths/min
   4. D. 60 to 80 breaths/min
   Show answer

   Answer: C. 30 to 60 breaths/min

   It settles toward 25 to 40 by the end of the first year.

3. An infant's birth weight usually doubles by about:

   1. A. 1 year
   2. B. 18 months
   3. C. 2 months
   4. D. 6 months
   Show answer

   Answer: D. 6 months

   It generally triples by about 1 year.

4. Newborns typically lose what portion of their birth weight in the first week?

   1. A. About 15 to 20 percent
   2. B. About 25 percent
   3. C. About 1 to 2 percent
   4. D. About 5 to 10 percent
   Show answer

   Answer: D. About 5 to 10 percent

   Most newborns lose about 5 to 10 percent of their birth weight in the first week as extra fluid is shed and feeding becomes established. The weight is regained within about two weeks. A loss of just 1 to 2 percent is smaller than typical, while losses of 15 percent or more suggest dehydration or a feeding problem.

5. The posterior fontanelle usually closes by about:

   1. A. 6 months
   2. B. 2 months
   3. C. 18 months
   4. D. 12 months
   Show answer

   Answer: B. 2 months

   The posterior fontanelle is small and usually closes by about 1 to 2 months of age. The anterior fontanelle stays open much longer, closing between about 12 and 18 months, so 12 and 18 months describe the anterior one. Six months is too late for the posterior fontanelle and too early for the anterior.

6. A sunken fontanelle in an infant suggests:

   1. A. Raised intracranial pressure
   2. B. Meningitis
   3. C. Dehydration
   4. D. Hydrocephalus
   Show answer

   Answer: C. Dehydration

   A bulging fontanelle suggests increased intracranial pressure.

7. The Moro reflex is:

   1. A. A head turn toward a touch on the cheek
   2. B. A startle with arms flung out, then drawn in
   3. C. Toe fanning when the sole is stroked
   4. D. A grasp of a finger placed in the palm
   Show answer

   Answer: B. A startle with arms flung out, then drawn in

   It is a startle response in which the infant throws the arms out and then draws them in. It fades by about 4 to 6 months.

8. The rooting reflex describes an infant who:

   1. A. Fans the toes when the sole is stroked
   2. B. Throws the arms out at a loud noise
   3. C. Grasps a finger placed in the palm
   4. D. Turns toward a stroked cheek
   Show answer

   Answer: D. Turns toward a stroked cheek

   The infant turns the head toward a cheek that is stroked, seeking to feed. It works with the sucking reflex during feeding.

9. Infants are obligate nose breathers, which means:

   1. A. They need higher respiratory rates than adults
   2. B. Nasal congestion can cause real distress
   3. C. Mouth breathing signals airway obstruction
   4. D. They cannot breathe through the mouth at all
   Show answer

   Answer: B. Nasal congestion can cause real distress

   Nasal obstruction from secretions can cause significant respiratory distress. Suctioning the nares can make a dramatic difference.

10. Compared with adults, infants have a proportionally:

    1. A. Larger head and tongue, narrower airway
    2. B. Stiffer chest wall and smaller tongue
    3. C. Longer neck and a lower-set larynx
    4. D. Smaller head and a wider, shorter trachea
    Show answer

    Answer: A. Larger head and tongue, narrower airway

    These differences shape airway positioning and management.

11. An infant's chest wall is more compliant than an adult's, which means:

    1. A. Organs can be injured with no rib fractures
    2. B. Breathing is more efficient than an adult's
    3. C. The lungs are better shielded from impact
    4. D. Ribs fracture easily with minimal force
    Show answer

    Answer: A. Organs can be injured with no rib fractures

    Significant internal injury can occur without rib fractures. Do not let intact ribs reassure you after chest trauma.

12. Infants rely on the diaphragm for breathing, so:

    1. A. Respiratory rates are slower than an adult's
    2. B. Accessory muscle use is a normal finding
    3. C. Intercostal muscles do most of the breathing work
    4. D. Abdominal distention can impair ventilation
    Show answer

    Answer: D. Abdominal distention can impair ventilation

    A distended stomach from aggressive ventilation worsens breathing.

13. Passive immunity in a newborn comes from:

    1. A. Early environmental antigen exposure
    2. B. The infant's own antibody production
    3. C. Hepatitis B vaccine given shortly after birth
    4. D. Maternal antibodies from placenta and milk
    Show answer

    Answer: D. Maternal antibodies from placenta and milk

    Maternal antibodies are transferred across the placenta and through breast milk. That protection fades over the first months of life.

14. According to Erikson, the developmental task of infancy is:

    1. A. Autonomy versus shame and doubt
    2. B. Trust versus mistrust
    3. C. Identity versus role confusion
    4. D. Initiative versus guilt
    Show answer

    Answer: B. Trust versus mistrust

    Consistent caregiving builds trust.

15. Bonding refers to:

    1. A. A reflexive response to the caregiver's voice
    2. B. The infant's wariness of unfamiliar adults
    3. C. The infant's ability to recognize faces
    4. D. Close emotional attachment to a caregiver
    Show answer

    Answer: D. Close emotional attachment to a caregiver

    Bonding is the formation of a close emotional attachment between infant and caregiver. It shapes later emotional development.

16. Safe sleep guidance to reduce sudden infant death syndrome includes:

    1. A. In the parents' bed with firm pillows
    2. B. On the back on a firm, empty surface
    3. C. Side-lying with a rolled blanket for support
    4. D. Prone with the head turned to the side
    Show answer

    Answer: B. On the back on a firm, empty surface

    Place infants on their backs on a firm surface without soft objects. The back-to-sleep message dropped SIDS rates substantially.

17. The neonatal period covers:

    1. A. The first 6 weeks of life
    2. B. The first 28 days
    3. C. The first 7 days of life
    4. D. The first year of life
    Show answer

    Answer: B. The first 28 days

    Neonates differ physiologically from older infants.

18. Average birth weight is approximately:

    1. A. 4 to 4.5 kg
    2. B. 2 to 2.5 kg
    3. C. 3 to 3.5 kg
    4. D. 1.5 to 2 kg
    Show answer

    Answer: C. 3 to 3.5 kg

    About 7 to 7.5 pounds.

19. The newborn's first breaths:

    1. A. Need high pressure to open fluid-filled lungs
    2. B. Are triggered only by suctioning the airway
    3. C. Need little effort, since the lungs are already dry
    4. D. Are passive and driven by chest recoil alone
    Show answer

    Answer: A. Need high pressure to open fluid-filled lungs

    Surfactant helps keep alveoli open afterward.

20. Fetal circulation changes at birth include:

    1. A. Ductus arteriosus opens to bypass the lungs
    2. B. Foramen ovale opens to shunt blood to the left
    3. C. Pulmonary vascular resistance rises sharply
    4. D. Ductus arteriosus and foramen ovale close
    Show answer

    Answer: D. Ductus arteriosus and foramen ovale close

    The ductus arteriosus and foramen ovale close as pulmonary pressure falls with the first breaths. Hypoxia can reverse these changes.

21. A newborn's normal systolic blood pressure is approximately:

    1. A. 60 to 70 mm Hg
    2. B. 100 to 120 mm Hg
    3. C. 90 to 110 mm Hg
    4. D. 40 to 50 mm Hg
    Show answer

    Answer: A. 60 to 70 mm Hg

    Blood pressure rises with age.

22. Infant heart rate at 1 year is approximately:

    1. A. 160 to 200
    2. B. 40 to 80
    3. C. 100 to 160
    4. D. 60 to 100
    Show answer

    Answer: C. 100 to 160

    Still faster than adults.

23. Infant temperature regulation is poor because:

    1. A. Large surface area, little fat, weak shivering
    2. B. Their sweat glands are overactive at birth
    3. C. Their metabolic rate is too low to generate heat
    4. D. Thick skin traps heat and causes overheating
    Show answer

    Answer: A. Large surface area, little fat, weak shivering

    They have a large surface area, little fat, and cannot shiver effectively. Keep them covered.

24. Brown fat in infants:

    1. A. Insulates by trapping heat beneath the skin
    2. B. Makes heat via nonshivering thermogenesis
    3. C. Is absent until several months of age
    4. D. Stores glycogen for later energy needs
    Show answer

    Answer: B. Makes heat via nonshivering thermogenesis

    A newborn's main heat source.

25. When opening the airway of a 4-month-old, why is a small towel placed under the shoulders?

    1. A. It lowers the larynx so that the tongue moves forward
    2. B. It keeps the infant warm during airway care
    3. C. The large occiput flexes the neck and can block it
    4. D. It hyperextends the neck to open the trachea
    Show answer

    Answer: C. The large occiput flexes the neck and can block it

    Infants have a large occiput that pushes the head forward when they lie supine, which flexes the neck and can kink the soft airway. A shoulder roll brings the airway to a neutral sniffing position. Hyperextension can also obstruct an infant airway. The larynx is high and anterior, and the roll does not lower it. Warmth is not its purpose.

26. An infant's large occiput means:

    1. A. The head flexes forward when supine
    2. B. The neck hyperextends when lying supine
    3. C. The larynx sits lower in the neck
    4. D. Neck alignment needs no padding
    Show answer

    Answer: A. The head flexes forward when supine

    Flexion of the head when supine can obstruct the airway. Neutral position is key.

27. Infant respiratory rate declines from about 40 at birth to about:

    1. A. 25 to 30 at 1 year
    2. B. About 50 to 60 at 1 year
    3. C. About 15 to 20 at 1 year
    4. D. About 10 to 12 at 1 year
    Show answer

    Answer: A. 25 to 30 at 1 year

    Still higher than adults.

28. Which feature makes infants more vulnerable to respiratory failure?

    1. A. Rigid ribs that resist chest expansion
    2. B. Slower breathing that limits ventilation
    3. C. Larger lung reserves that mask distress
    4. D. Fewer alveoli and higher oxygen demand
    Show answer

    Answer: D. Fewer alveoli and higher oxygen demand

    Infants have fewer alveoli, weaker respiratory muscles, and higher oxygen demand per kilogram, so they fatigue quickly. Their ribs are soft and compliant rather than rigid, they breathe faster, not slower, than adults, and their respiratory reserve is small, not large.

29. The sucking reflex:

    1. A. Persists normally into adulthood
    2. B. Signals a neurologic problem
    3. C. Appears around 6 months of age
    4. D. Is present at birth
    Show answer

    Answer: D. Is present at birth

    It is present at birth and essential for feeding. Absence suggests a neurologic problem.

30. The grasp reflex:

    1. A. Persists into the school years
    2. B. Is voluntary from birth onward
    3. C. Appears around 1 year of age
    4. D. Fades by 3 to 4 months
    Show answer

    Answer: D. Fades by 3 to 4 months

    The palmar grasp is present at birth and fades by about 3 to 4 months.

31. The Babinski reflex in infants:

    1. A. Signals spinal cord injury in infants
    2. B. Is abnormal and suggests brain injury
    3. C. Is normal until 12 to 24 months
    4. D. Is absent until the infant begins walking
    Show answer

    Answer: C. Is normal until 12 to 24 months

    Fanning of the toes upward is normal in infants; it is abnormal after walking begins.

32. Persistence of primitive reflexes beyond the usual age suggests:

    1. A. Normal variation in development
    2. B. A temporary nutritional deficit
    3. C. Possible neurologic problem
    4. D. Advanced motor development
    Show answer

    Answer: C. Possible neurologic problem

    Developmental assessment.

33. By 2 months, most infants can:

    1. A. Crawl and pull up to a standing position
    2. B. Roll over from back to front repeatedly
    3. C. Sit without support and reach for toys
    4. D. Lift head when prone and smile socially
    Show answer

    Answer: D. Lift head when prone and smile socially

    Social smile is an important milestone.

34. By 4 months, most infants can:

    1. A. Crawl forward steadily on hands and knees
    2. B. Roll front to back and hold head steady
    3. C. Sit without support for long periods
    4. D. Pull to stand while holding furniture
    Show answer

    Answer: B. Roll front to back and hold head steady

    Rolling means falls from surfaces.

35. By 6 months, most infants can:

    1. A. Walk a few steps while holding furniture
    2. B. Stand alone briefly without holding on
    3. C. Climb onto low furniture independently
    4. D. Sit with support, pass toys between hands
    Show answer

    Answer: D. Sit with support, pass toys between hands

    Most can sit with support and transfer objects between hands. Teeth often begin.

36. By 9 months, most infants can:

    1. A. Run short distances without falling
    2. B. Sit alone, crawl, and pull to stand
    3. C. Climb stairs with one hand held
    4. D. Walk alone and stoop to pick up toys
    Show answer

    Answer: B. Sit alone, crawl, and pull to stand

    Stranger anxiety peaks.

37. By 12 months, most infants can:

    1. A. Kick a ball and name body parts
    2. B. Run steadily and speak in phrases
    3. C. Climb stairs and use two-word phrases
    4. D. Stand alone and say a few words
    Show answer

    Answer: D. Stand alone and say a few words

    Most stand alone, may take first steps, and say a few words. Wide variation is normal.

38. A 12-month-old says no words and does not respond to her name. How should you interpret this?

    1. A. Normal; first words appear around age 3
    2. B. Normal; most infants do not respond to their names yet
    3. C. Expected if she was born at full term
    4. D. Possible developmental delay; arrange follow-up
    Show answer

    Answer: D. Possible developmental delay; arrange follow-up

    Most infants respond to their name by about 9 months and say a word such as 'mama' or 'dada' by 12 months. Missing both suggests hearing loss or developmental delay (including autism) and should prompt pediatric follow-up. First words do not wait until age 3. Prematurity, not term birth, is the reason to adjust milestone expectations.

39. Stranger anxiety typically begins around:

    1. A. 18 to 24 months
    2. B. 6 to 9 months
    3. C. 3 to 4 years
    4. D. 2 to 4 months
    Show answer

    Answer: B. 6 to 9 months

    Assess with the caregiver holding the infant.

40. Infant feeding progresses from:

    1. A. Breast milk to whole cow's milk at 2 months
    2. B. Milk or formula to solids around 6 months
    3. C. Formula to whole cow's milk near 4 months
    4. D. Cereal at birth, then formula at 3 months
    Show answer

    Answer: B. Milk or formula to solids around 6 months

    Cow's milk is delayed until 12 months.

41. Breastfeeding provides:

    1. A. Antibodies but inadequate protein for growth
    2. B. Nutrition but no immune protection
    3. C. Nutrition, antibodies, and bonding
    4. D. Comfort without meaningful nutrition
    Show answer

    Answer: C. Nutrition, antibodies, and bonding

    IgA in breast milk.

42. Infant immunizations begin:

    1. A. At 12 months, once immunity matures
    2. B. At birth, continuing through childhood
    3. C. At 6 months, when maternal antibodies fade
    4. D. At school entry, before group exposure
    Show answer

    Answer: B. At birth, continuing through childhood

    Hepatitis B at birth.

43. A 6-week-old has a fever of 38.4 C (101.1 F) but looks well. Why does this still need urgent evaluation?

    1. A. Young infants run higher fevers than older children do
    2. B. Immature immunity can hide serious bacterial infection
    3. C. Maternal antibodies make any fever more dangerous
    4. D. A fever this low is nearly always caused by teething
    Show answer

    Answer: B. Immature immunity can hide serious bacterial infection

    Infants under about 3 months have immature immune systems and depend partly on maternal antibodies, so they can have bacteremia, UTI, or meningitis with few signs. Any fever needs prompt evaluation. Young infants often mount weak fevers or even low temperatures, not higher ones, so a modest fever can still mark serious infection. Maternal antibodies are protective. Teething does not explain a fever.

44. Fever in an infant under 3 months:

    1. A. Is routine after vaccines and can be observed
    2. B. Needs urgent evaluation for infection
    3. C. Can be managed at home with antipyretics
    4. D. Is a normal response to teething
    Show answer

    Answer: B. Needs urgent evaluation for infection

    The risk of serious bacterial infection is high. Low threshold for transport.

45. Why does dehydration develop rapidly in infants?

    1. A. High water turnover and limited reserves
    2. B. A low metabolic rate that slows fluid use
    3. C. Mature kidneys that excrete free water quickly
    4. D. Lower total body water than adults
    Show answer

    Answer: A. High water turnover and limited reserves

    Infants have a high metabolic rate, turn over a large share of their body water each day, and have small reserves, so vomiting, diarrhea, or poor intake dehydrates them quickly. Their metabolic rate is high rather than low, their kidneys are immature and concentrate urine poorly, and their total body water percentage is higher than an adult's, not lower. Count wet diapers.

46. Infant kidney function:

    1. A. Stronger than an adult's at clearing drugs
    2. B. Not functional until several weeks of age
    3. C. Immature; it concentrates urine poorly
    4. D. Mature at birth, matching adult function
    Show answer

    Answer: C. Immature; it concentrates urine poorly

    Immature kidneys have limited ability to concentrate urine. Fluid and drug handling differ.

47. Infant liver function:

    1. A. Mature, so drug doses match adult per-kilogram doses
    2. B. Immature, affecting drug and bilirubin handling
    3. C. Nonfunctional until about 1 month of age
    4. D. More efficient than an adult's at clearing drugs
    Show answer

    Answer: B. Immature, affecting drug and bilirubin handling

    Jaundice is common.

48. Physiologic jaundice in newborns:

    1. A. Common in the first week of life
    2. B. Most concerning when it appears on day 4
    3. C. Caused by blood group incompatibility
    4. D. Usually first visible within 24 hours of birth
    Show answer

    Answer: A. Common in the first week of life

    Physiologic jaundice is common in the first week of life and results from immature bilirubin processing. It usually appears after the first day and peaks around days 3 to 5. Jaundice in the first 24 hours is pathologic and concerning, and jaundice from blood group incompatibility is hemolytic rather than physiologic.

49. Infant bone development:

    1. A. Brittle bones that fracture with minimal force
    2. B. Fully calcified bones similar to an adult's
    3. C. Soft, flexible bones with open growth plates
    4. D. Closed growth plates by the end of the first year
    Show answer

    Answer: C. Soft, flexible bones with open growth plates

    Fractures in infants raise abuse concern.

50. Infant skin:

    1. A. Thick and resistant to absorption
    2. B. Identical to adult skin in function
    3. C. Waterproof due to vernix after birth
    4. D. Thin and absorbs substances easily
    Show answer

    Answer: D. Thin and absorbs substances easily

    Topical medications absorb more.

51. Infant pain perception:

    1. A. Absent until nerves myelinate later
    2. B. Impossible to assess without verbal report
    3. C. Present and should be assessed and treated
    4. D. Present but much weaker than an adult's
    Show answer

    Answer: C. Present and should be assessed and treated

    Use behavioral pain scales.

52. Infant vision at birth:

    1. A. Blurry, best focused at 8 to 12 inches
    2. B. Sharp, with near-adult acuity at birth
    3. C. Absent until about 2 months of age
    4. D. Limited to light and dark for months
    Show answer

    Answer: A. Blurry, best focused at 8 to 12 inches

    Faces are the preferred object.

53. Infant hearing at birth:

    1. A. Limited to very loud, low sounds
    2. B. Present, with response to voices
    3. C. Absent until the ear canals clear
    4. D. Develops around 6 months of age
    Show answer

    Answer: B. Present, with response to voices

    Hearing screening at birth.

54. Trust in infancy develops through:

    1. A. Frequent exposure to new caregivers
    2. B. Early, consistent discipline and routines
    3. C. Encouraging early independence from parents
    4. D. Consistent, responsive caregiving
    Show answer

    Answer: D. Consistent, responsive caregiving

    Erikson's first stage.

55. A 10-month-old screams when separated from her mother but calms when placed back in her lap. How should you examine her?

    1. A. In her mother's lap, starting with the least invasive
    2. B. Away from the mother, so the infant is not distracted
    3. C. Quickly, with the infant held down on the stretcher
    4. D. Only after the mother leaves the room
    Show answer

    Answer: A. In her mother's lap, starting with the least invasive

    Attachment to a primary caregiver and stranger anxiety are normal at this age. Keeping the infant in the caregiver's lap and starting with observation and the least threatening steps gives you a calmer, more accurate exam. Separation and restraint increase crying, heart rate, and respiratory rate, which hides real findings.

56. Temperament in infants:

    1. A. Is essentially identical in healthy infants
    2. B. Varies: easy, difficult, or slow to warm
    3. C. Is learned entirely from caregiver behavior
    4. D. Does not appear until the toddler years
    Show answer

    Answer: B. Varies: easy, difficult, or slow to warm

    Affects caregiver interaction.

57. Colic is:

    1. A. A bacterial infection of the bowel
    2. B. A marker of caregiver neglect or abuse
    3. C. Prolonged crying in a healthy infant
    4. D. A sign of intestinal obstruction
    Show answer

    Answer: C. Prolonged crying in a healthy infant

    It usually resolves by 3 to 4 months. Exhausting for caregivers.

58. Caregiver frustration with crying is a risk factor for:

    1. A. Abusive head trauma
    2. B. Failure to thrive
    3. C. Infant sleep apnea
    4. D. Worsening infant colic
    Show answer

    Answer: A. Abusive head trauma

    Teaching coping strategies prevents it.

59. A 7-month-old with fever and vomiting has a tense, bulging anterior fontanelle while calm and upright. This suggests:

    1. A. Raised intracranial pressure, such as meningitis
    2. B. Dehydration that can be managed with oral fluids at home
    3. C. A normal finding in a crying or calm infant
    4. D. Early closure of the posterior fontanelle
    Show answer

    Answer: A. Raised intracranial pressure, such as meningitis

    The anterior fontanelle stays open until about 12 to 18 months. A tense, bulging fontanelle in a calm, upright infant suggests raised intracranial pressure (meningitis, bleeding, hydrocephalus) and needs emergency care. Dehydration causes a sunken fontanelle. Crying can make it bulge briefly, which is why you assess it with the infant calm and upright. The posterior fontanelle closes by about 1 to 2 months and is not the finding here. (Replaces a second safe-sleep item that repeated s01-q016.)

60. Infant car seats should be:

    1. A. Forward facing once the infant can sit
    2. B. In the front seat for easy monitoring
    3. C. Rear facing as long as possible
    4. D. Forward facing after 6 months of age
    Show answer

    Answer: C. Rear facing as long as possible

    Rear facing as long as possible per current guidelines protects the head and neck.

61. Assessing an infant should begin with:

    1. A. Auscultation of breath sounds first
    2. B. A hands-on head-to-toe examination
    3. C. A full set of measured vital signs
    4. D. Observation from across the room
    Show answer

    Answer: D. Observation from across the room

    Use the Pediatric Assessment Triangle from a distance: appearance, work of breathing, circulation to skin.

62. Infant blood pressure measurement:

    1. A. The best indicator of perfusion
    2. B. Often unreliable in the field
    3. C. Required before any treatment
    4. D. Accurate with any available cuff
    Show answer

    Answer: B. Often unreliable in the field

    It is difficult to obtain in the field; other perfusion signs such as capillary refill and mental status matter more.

63. Infant weight estimation uses:

    1. A. Head circumference measured with a tape
    2. B. A length-based tape or caregiver report
    3. C. An adult weight formula scaled by age
    4. D. Visual estimation by the treating crew
    Show answer

    Answer: B. A length-based tape or caregiver report

    Dosing depends on it.

64. Infant mortality is highest in:

    1. A. Months 2 through 4 of life
    2. B. The second year of life
    3. C. Months 6 through 12 of life
    4. D. The first month of life
    Show answer

    Answer: D. The first month of life

    The neonatal period carries the highest mortality, from prematurity and congenital conditions.

65. Which infant finding is most concerning?

    1. A. Vigorous, loud crying when handled
    2. B. Active movement of all extremities
    3. C. A strong suck on a pacifier
    4. D. Lethargy, poor tone, or a weak cry
    Show answer

    Answer: D. Lethargy, poor tone, or a weak cry

    A quiet infant may be a sick infant.

66. Which infant finding suggests respiratory distress?

    1. A. Pink skin and a regular respiratory rate
    2. B. Nasal flaring, grunting, and retractions
    3. C. Periodic breathing with brief 5-second pauses
    4. D. Quiet, unlabored breathing during sleep
    Show answer

    Answer: B. Nasal flaring, grunting, and retractions

    Head bobbing also indicates severe effort.