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 C
Explanation
A. While hydrogen peroxide has some disinfectant properties, it is not as effective as other agents like chlorine bleach for cleaning surfaces contaminated with blood.
B. Isopropyl alcohol is effective against many pathogens but may not be as effective as chlorine bleach specifically for bloodborne pathogens.
C. Chlorine bleach is an effective agent for cleaning surfaces contaminated with blood and other bodily fluids, as it has strong disinfectant properties.
D. Chlorhexidine is primarily used as an antiseptic for skin preparation and may not be as effective for surface cleaning of blood contamination.
Correct Answer is B
Explanation
A. Administering furosemide may also be appropriate for managing heart failure symptoms, but the priority action based on the client's condition is to withhold digoxin.
B. The client's vital signs indicate bradycardia (pulse 52/min), which is a common adverse effect of digoxin, especially in the setting of heart failure. Withholding digoxin is necessary to prevent further exacerbation of bradycardia and potential toxicity.
C. Withholding spironolactone may be considered if there are concerns about electrolyte imbalances, but it is not the priority action in this scenario.
D. Administering ferrous sulfate is not indicated based on the client's chart findings; there is no indication of anemia or iron deficiency.
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