A community health nurse is performing a vision screening on a 4-month-old infant. When shining a light source into the infant's visual field, which of the following is an expected finding?
The infant's eyes turn toward the light.
The infant's head turns away from the light.
The infant's eyes remain focused toward the floor.
The infant closes their eyes.
The Correct Answer is A
A.
A. The infant's eyes turn toward the light - This is the expected finding known as the "fixation reflex," where infants naturally turn their eyes toward a light source.
B. The infant's head turns away from the light - This would not be an expected finding during a vision screening; it may suggest a different reflex or issue.
C. The infant's eyes remain focused toward the floor - This would not be an expected finding during a vision screening; it may suggest a different visual or developmental concern.
D. The infant closes their eyes - Closing the eyes in response to light is not the typical response during a vision screening for infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Levothyroxine is a thyroid hormone replacement medication commonly used to treat hypothyroidism. It is not associated with teratogenic effects when used appropriately.
B. Phenytoin is an anticonvulsant medication that is known to be teratogenic, especially when used during the first trimester of pregnancy. It is associated with an increased risk of congenital malformations, such as cleft palate and heart defects, in infants born to mothers who take the medication during pregnancy.
C. Magnesium oxide is a mineral supplement commonly used to treat constipation during pregnancy. It is not associated with teratogenic effects when used appropriately.
D. Ferrous sulfate is an iron supplement commonly used to treat chronic anemia during pregnancy. It is not associated with teratogenic effects when used appropriately.
Correct Answer is D
Explanation
A. 1 cm of water present in the water seal chamber is within the expected range.
B. Tidaling with spontaneous respirations indicates the system is functioning properly.
C. Suction chamber pressure of -20 cm H2O is within the expected range for adequate suction.
D. The drainage collection chamber being one-third full suggests an accumulation of fluid beyond the expected level, which may indicate a potential complication such as hemorrhage or fluid buildup in the pleural space, requiring intervention by the nurse.
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