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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Assess the parents’ anxiety level and readiness to learn. This is because the nurse needs to evaluate the parent’s emotional state and their ability to comprehend and retain information before providing any teaching.
The nurse should also consider the parent'slearning style, cultural background, and literacy level.
Choice B is wrong because gathering literature for the parents is not the first action. The nurse should first assess the parents’ needs and preferences and then select appropriate materials that match their level of understanding and language.
Choice C is wrong because securing a quiet place for teaching is not the first action. The nurse should first assess the parents’ readiness to learn and then choose a suitable environment that minimizes distractions and promotes comfort.
Choice D is wrong because discussing the plan with the nursing team is not the first action. The nurse should first assess the parents’ anxiety level and readiness to learn and then collaborate with other health care professionals to provide consistent and accurate information.
Correct Answer is B
Explanation
This is because oil peppermint can stimulate the micturition reflex and help the woman to void.
Some possible explanations for the other choices are:
Choice A is wrong because pouring water over the perineum may not be enough to trigger the micturition reflex and may cause discomfort or infection.
Choice C is wrong because analgesics may not address the underlying cause of urinary retention and may have side effects such as drowsiness or nausea.
Choice D is wrong because inserting a sterile catheter is an invasive procedure that carries risks such as trauma, infection, or bladder spasms. It should be used only as a last resort after other methods have failed.
Normal ranges for postpartum bladder function are:
- Urine output: 3000 to 5000 mL/day for the first 2 to 3 days after delivery.
- Urine specific gravity: 1.005 to 1.030.
- Urine pH: 4.6 to 8.0.
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