A nurse in a pediatric clinic is assessing a 6-month-old infant. Which of the following findings should the nurse identify as an indication of a visual Impairment?
The infant reacts to bright light.
The infant's corneal light reflex is symmetrical.
The infant does not fixate and follow an object.
The infant's red reflex is present bilaterally.
The Correct Answer is C
A. The infant reacts to bright light. Reacting to bright light is a normal response and indicates that the infant can see. This does not indicate a visual impairment.
B. The infant's corneal light reflex is symmetrical. A symmetrical corneal light reflex indicates proper eye alignment and does not suggest a visual impairment.
C. The infant does not fixate and follow an object. By 6 months, an infant should be able to fixate on and follow an object. Failure to do so can be an indication of a visual impairment.
D. The infant's red reflex is present bilaterally. A normal red reflex in both eyes indicates that the eyes are clear and healthy. Absence of the red reflex could suggest a problem, but its presence does not indicate impairment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
A. Varicella (VAR): The first dose of the varicella vaccine is recommended at 12 to 15 months of age.
B. Human papillomavirus (HPV4): The HPV vaccine is not recommended until adolescence, starting at 11 to 12 years of age.
C. Measles, mumps, and rubella (MMR): The first dose of the MMR vaccine is recommended at 12 to 15 months of age.
D. Rotavirus (RV): The rotavirus vaccine series should be completed by 8 months of age. It is not given at 12 months.
E. Herpes zoster: The herpes zoster (shingles) vaccine is recommended for older adults, not infants.
Correct Answer is C
Explanation
A. Give the child small sips of water. Giving water can be helpful, but frequent throat clearing may indicate bleeding, which should be assessed first.
B. Administer an analgesic. Pain management is important, but the immediate concern should be to rule out postoperative bleeding.
C. Observe the child's throat with a flashlight. Frequent throat clearing can be a sign of bleeding. The nurse should inspect the throat first to check for signs of hemorrhage, which is a serious complication.
D. Offer the child an ice collar. An ice collar can help reduce swelling and pain but should be done after assessing for bleeding.
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