During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes.
The nurse should recognize that this is:.

A normal finding

An abnormal finding: the child needs referral to an ophthalmologist

A sign of a possible visual defect; the child needs vision screening

A sign of small hemorrhages, which usually resolve spontaneously

Answer and Explanation

The Correct Answer is A

A brilliant, uniform red reflex in both eyes is a sign of a healthy retina and optic nerve. The red reflex is the reflection of light from the retina that varies in color depending on the patient’s skin tone. It can be seen by holding the ophthalmoscope directly in front of your eye and asking the patient to focus on a point in the distance.

Choice B is wrong because an abnormal finding would be an absent or asymmetric red reflex, which could indicate cataracts, retinal detachment, or other eye diseases.

Choice C is wrong because a possible visual defect would not affect the red reflex, but rather the visual acuity or field of vision of the patient.

A vision screening would involve testing the patient’s ability to read letters or numbers at different distances.

Choice D is wrong because small hemorrhages would not cause a brilliant, uniform red reflex, but rather dark spots or blotches on the retina that can be seen with the ophthalmoscope.

Hemorrhages can be caused by diabetes, hypertension, or trauma.

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Correct Answer is A

Explanation

“You may need to increase the caloric density of your infant’s formula.” This is because infants with heart failure have increased metabolic needs and may not be able to consume enough volume to meet their nutritional requirements. Increasing the caloric density of the formula can help them achieve adequate growth and development without overloading their heart.

Choice B is wrong because feeding the baby every 2 hours may cause fatigue and dehydration. Infants with heart failure should be fed every 3 to 4 hours or on demand.

Choice C is wrong because increasing the amount of formula may cause fluid retention and worsen heart failure. Infants with heart failure should be fed small, frequent amounts of formula.

Choice D is wrong because placing a nasal oxygen cannula on the infant during and after each feeding may not be necessary or beneficial. Oxygen therapy should be prescribed by a physician based on the infant’s oxygen saturation levels and clinical signs of hypoxia.

A. Rubella B. Measles (rubeola) C. Chickenpox (varicella) D. Exanthema subitum (roseola)

Correct Answer is B

Explanation

Measles (rubeola) is a communicable disease that is characterized by Koplik’s spots, which are clustered, white lesions on the buccal mucosa opposite the lower molars. They appear two to three days before the measles rash and are pathognomonic for measles.

Choice A is wrong because rubella is a different viral infection that causes a mild rash and fever, but does not have Koplik’s spots.

Choice C is wrong because chickenpox (varicella) is caused by the varicella-zoster virus and produces fluid-filled blisters on the skin, not white spots in the mouth.

Choice D is wrong because exanthema subitum (roseola) is caused by the human herpesvirus 6 or 7 and causes a high fever followed by a pink rash on the trunk and neck, but no oral lesions.

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During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is:.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is talking to a parent of an infant with heart failure about feeding the infant. Which statement about feeding the child is correct?

Correct Answer is A

Explanation

The nurse is performing an assessment on a child and notes the presence of Koplik’s spots. In which communicable disease are Koplik’s spots present?

Correct Answer is B

Explanation

What is the nurse’s first action when planning to teach the parents of an infant with a congenital heart defect (CHD)?

A school-age child is admitted in vaso-occlusive sickle cell crisis. The child’s care should include which intervention? (Select all that apply.)

A premature infant with respiratory distress syndrome receives artificial surfactant. How would the nurse explain surfactant therapy to the parents?

Parents of a school-age child with hemophilia ask the nurse, “Which sports are recommended for children with hemophilia?” Which sport should the nurse recommend?

Medications used to manage postpartum hemorrhage (PPH) include (Select all that apply.):.

The nurse is assessing a child with acute epiglottitis. Examining the child’s throat by using a tongue depressor might precipitate which symptom or condition?

A nurse is conducting discharge and teaches parents about the care of their infant after cardiac surgery. The nurse instructs the parents to notify the physician if the conditions occur. (Select all that apply.)

Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, the last thing the nurse could try is:

During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes.
The nurse should recognize that this is:.