In Assessing the Eyes of a 4-Month-Old Infant, a Nurse

question 6

Multiple Choice

In assessing the eyes of a 4-month-old infant, a nurse shines a penlight in the infant's eyes and notices that the light reflection is not in the same location in each eye. What is the nurse's most appropriate response to this finding?

• A) Perform the cover-uncover test.
• B) Document it as an expected finding at this age.
• C) Document abnormal function of cranial nerves IV (trochlear) and VI (abducens).
• D) Refer the infant to an ophthalmologist.