When caring for a child with Kawasaki disease, the nurse should understand that principle of care?

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.

This pattern is called periodic breathing and it is characterized by 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration. It is a normal phenomenon that occurs primarily in premature infants of more than 24 hours of age. It is usually not of pathologic significance and does not require intervention.

Choice A is wrong because sleep or wakeful apnea is defined as a cessation of breathing for more than 20 seconds or less than 20 seconds with bradycardia or cyanosis.

Choice B is wrong because severe swings in blood pressure are not associated with periodic breathing, but rather with intraventricular hemorrhage or patent ductus arteriosus.

Choice C is wrong because trying to maintain a neutral thermal environment does not affect the respiratory pattern of premature infants.

Normal ranges for respiratory rate in premature infants are 40 to 60 breaths per minute. Normal ranges for oxygen saturation in premature infants are 88% to 92%.