When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should:
a. Consider this a normal finding.
b. Refer the individual for further evaluation.
c. Document this finding as an asymmetric light reflex.
d. Perform the confrontation test to validate the findings.
ANS: A
Reflection of the light on the corneas should be in exactly the same spot on each eye, or symmetric. If asymmetry is noted, then the nurse should administer the cover test.
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