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 C

Explanation

Placing eye shields over the newborn’s closed eyes. This is because phototherapy can cause eye damage and irritation to the newborn, so eye protection is essential.

Choice A is wrong because oil-based lotion can increase the absorption of heat and cause burns to the newborn’s skin.

Choice B is wrong because limiting the newborn’s intake of milk can cause dehydration and increase the risk of hyperbilirubinemia.

Choice D is wrong because changing the newborn’s position every 4 hours is not frequent enough to prevent pressure ulcers and ensure even exposure to the light.

Normal ranges for bilirubin levels in newborns are 1 to 12 mg/dL for term infants and 3 to 14 mg/dL for preterm infants. Phototherapy is usually indicated when the bilirubin level exceeds 15 mg/dL for term infants and 10 mg/dL for preterm infants.

A. Review of systems. B. Physical assessment. C. Sexual history. D. Height, Weight, BMI data. E. Diet and nutritional intake. F. Family medical history.

Correct Answer is ["A","C","D","E","F"]

Explanation

A health history is a holistic assessment of all factors affecting a patient’s health status, including information about social, cultural, familial, and economic aspects of the patient’s life as well as any other component of the patient’s life style that affects health and well-being.

Choice B is wrong because physical assessment is not part of the health history, but a separate process of examining the patient’s body systems.

Choice A is correct because review of systems is a systematic method of collecting data on all body systems.

Choice C is correct because sexual history is an important aspect of the patient’s health that may affect their risk for sexually transmitted infections, reproductive health, and psychosocial well-being.

Choice D is correct because height, weight, BMI data are part of the biographical data that provide a baseline for comparing the patient’s characteristics to established norms for physical and emotional health.

Choice E is correct because diet and nutritional intake are relevant factors that influence the patient’s health status and may indicate potential problems such as malnutrition, obesity, or eating disorders.

Choice F is correct because family medical history provides information about the patient’s genetic risk for certain diseases and conditions that may affect their current or future health.

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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

A newborn is jaundiced and receivesphototherapy via ultraviolet bank lights. An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to:

Correct Answer is C

Explanation

Which data would be included in a health history? (Select all that apply.).

Correct Answer is ["A","C","D","E","F"]

Explanation

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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:.