The nurse is examining the eyes of a newborn infant. If the nurse notes the absence of the red reflex, what is the next best action?
a. Notify the physician.
b. Document the finding in the records.
c. Recheck the reflex after several hours.
d. Monitor the eye movements and pupil reactions closely.
ANS: A
The absence of the red reflex suggests the presence of congenital cataracts, which is an abnormal finding. It will not change in several hours, nor do the eye movements and pupil reaction provide significant changes in this situation.
You might also like to view...
When documenting an incident in the nurse's notes, what should the nurse include? (Select all that apply.)
a. Description of injury, including diagrams of injury placement b. Date, time, and location of incident c. Name of physician and family members notified d. Chronological order of events of the incident e. Confirmation that an incident report was initiated
The major responsibility for upholding patient care standards belongs to the:
a. chief executive officer of the facility. b. nurse manager. c. on-call physician. d. staff nurse providing patient care.
A patient comes into the emergency department with complaints of chest pains. An ECG reveals an acute myocardial infarction taking place. You would expect the physician to take which ac-tion?
1. Send the patient directly to the cardiac unit for follow-up care. 2. Give the patient one aspirin and repeat the ECG. 3. Administer a thrombolytic agent for lysis of thrombi. 4. Administer heparin only to prevent potential bleeding of coronary arteries.
A client asks how soon after a mastectomy she can engage in sexual activity. Which is the nurse's best response?
a. "When do you want to resume sexual ac-tivity?" b. "Most surgeons say to wait several weeks after the operation." c. "As soon as the incision has healed com-pletely." d. "You shouldn't worry about sexuality right now."