Which explains the importance of detecting strabismus in young children?

Correct Answer: B

Rationale: In nursing care of children, detecting strabismus early is crucial for optimal vision development. The correct answer is B) Amblyopia, a type of blindness, may result. Strabismus, if left untreated, can lead to amblyopia, where the brain starts to favor one eye over the other, causing vision loss in the weaker eye. This highlights the importance of early detection and intervention to prevent long-term visual impairment. Option A) Color vision deficit may result is incorrect because strabismus primarily affects binocular vision and eye alignment, not color vision. Option C) Epicanthal folds may develop in the affected eye is incorrect as epicanthal folds are unrelated to strabismus but are a common feature in some individuals. Option D) Corneal light reflexes may fall symmetrically within each pupil is incorrect because this statement describes a normal finding, not a consequence of strabismus. Educationally, understanding the implications of untreated strabismus emphasizes the importance of regular vision screenings in children to detect and address visual abnormalities early to promote optimal eye health and development. Nurses play a vital role in advocating for comprehensive eye exams and timely interventions to prevent complications like amblyopia.

Correct Answer: C

Rationale: In assessing an infant's visual acuity, it is crucial to understand the developmental milestones related to vision. Infants typically develop the ability to fixate on and follow a target between 3 to 4 months of age. At this stage, their visual system is becoming more coordinated, allowing them to track moving objects with their eyes. This ability is a key indicator of visual maturation and neurological development in infants. Option A (1 month) is incorrect because infants at this age do not yet possess the visual acuity and coordination required to fixate and follow a target accurately. Option B (1 to 2 months) is also incorrect as it falls within the same reasoning as option A. Option D (6 months) is incorrect as well because by this age, infants should have already developed the ability to fixate on and follow a target. Infants who have not achieved this milestone by 6 months may require further evaluation for potential visual or neurological issues. Understanding these developmental milestones is essential for nurses caring for infants as it allows for early detection of any visual or neurological abnormalities. By recognizing the expected age range for visual acuity development, nurses can provide appropriate interventions and referrals to support optimal infant growth and development.

Correct Answer: C

Rationale: In an otoscopic examination on an infant, the correct direction to pull the pinna is down and back (Option C). This technique is used to straighten the ear canal in infants, as their ear canals are angled differently than in adults. Pulling the pinna down and back helps to align the ear canal for better visualization and to prevent any potential injury to the infant's delicate ear structures. This direction also helps in opening up the ear canal for a clearer view of the tympanic membrane. The other options (A) Up and back, (B) Up and forward, and (D) Down and forward are incorrect because pulling the pinna in those directions can lead to a more acute angle of the ear canal, making it harder to visualize the tympanic membrane and potentially causing discomfort or harm to the infant. Educationally, understanding the correct technique for an otoscopic examination in infants is crucial for nursing students to provide safe and effective care. It ensures proper assessment of the ear structures and helps prevent complications that may arise from incorrect manipulation of the pinna. Practicing and mastering this skill is essential for pediatric nursing care.

Correct Answer: C

Rationale: In the context of pediatric nursing, conducting hearing screenings in children is crucial for early detection of hearing impairments. The appropriate screening test for hearing in a 5-year-old child is option C, Pure tone audiometry. This test is chosen because it is specifically designed to assess the hearing threshold levels in children by measuring their ability to hear different frequencies. Option A, the Rinne test, and option B, the Weber test, are both tests used to differentiate between conductive and sensorineural hearing loss in adults and are not suitable for hearing screening in young children. Option D, eliciting the startle reflex, is not a reliable or standardized method for hearing screening in children. It may indicate a response to sound but does not provide accurate information about the child's hearing thresholds across different frequencies. Educationally, understanding the appropriate screening tools for various age groups is essential for nurses working in pediatric settings to ensure early detection and intervention for any hearing impairments that could impact a child's development. Conducting regular screenings using appropriate methods can help in identifying issues early and providing timely support and interventions.

Correct Answer: B

Rationale: In pediatric nursing, the appropriate placement of a tongue blade for assessment of the mouth and throat is on the side of the tongue. This placement allows for visualization of the oral cavity structures without triggering the gag reflex in children. Placing the tongue blade on the lower jaw (option A) would not provide a clear view of the mouth and throat. Placing it against the soft palate (option C) can cause discomfort and trigger the gag reflex. Placing it in the center back area of the tongue (option D) may also induce the gag reflex and hinder a comprehensive assessment. Educationally, understanding the correct placement of a tongue blade is crucial for pediatric nurses to perform thorough assessments while ensuring the comfort and cooperation of the child. By placing the tongue blade correctly, nurses can visualize the oral cavity effectively, identify any abnormalities, and provide appropriate care. It is essential for nurses to be knowledgeable about proper assessment techniques to deliver safe and effective care to pediatric patients.