A nurse assesses a whitish reflection instead of the expected red reflex when evaluating an infant's eyes. Which action should the nurse take?
a. Notify the physician.
b. Chart the finding.
c. Check the chart to verify that the infant received eye prophylaxis at birth.
d. Reassess for a red reflex in 1 month.
A
A whitish reflex in the eye, leukocoria, is a common finding of retinoblastoma. It is an overt sign of cancer and the physician needs to be notified. Checking the chart for routine eye prophylaxis at birth would be done if there was an eye infection. The finding is not normal and by charting the finding or reassessing in 1 month treatment will be delayed.
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