A nurse is caring for a client who has a pressure injury on the coccyx. Which of the following findings should indicate to the nurse that the wound is a stage III pressure injury?

A. Remove the skin markings following radiation: Skin markings should not be removed during radiation therapy, as they are necessary for accurate targeting of radiation. Removing them can interfere with treatment accuracy and is not recommended.

B. Apply lotions liberally to the skin: While moisturizing can help with dryness, during radiation therapy, the nurse should recommend only mild, non-irritating, fragrance-free lotions approved by the radiation team. Applying products liberally or unapproved lotions can interfere with radiation dosing.

C. Wear protective clothing when outside: Radiation can make the skin more sensitive to sunlight. Wearing protective clothing and using sun protection helps prevent additional irritation, burns, or damage to already vulnerable skin. This is an appropriate measure to manage skin integrity.

D. Cleanse skin with an antibacterial cleanser: Antibacterial or harsh cleansers can irritate the sensitive skin of a child undergoing radiation therapy. Gentle, mild, fragrance-free soap and lukewarm water are preferred to maintain skin integrity without causing further damage.

A. "The test will determine if there is leaking amniotic fluid.": The nitrazine test is used to detect the presence of amniotic fluid in the vagina by measuring pH. A positive result indicates a more alkaline pH, suggesting rupture of membranes. This explanation accurately describes the purpose of the test to the client.

B. "Your bladder should be full prior to me performing this test.": A full bladder is not required for a nitrazine test. In fact, urine can interfere with results because it is acidic and may cause a false-negative reading, so the bladder should not influence the test outcome.

C. "I will be taking a blood sample to test for changes in your hormone levels.": The nitrazine test does not involve blood samples and is unrelated to hormone levels. It is performed using vaginal fluid to detect amniotic fluid, so this statement is inaccurate.

D. "If this test is positive you will be required to have a non-stress test.": A positive nitrazine test indicates ruptured membranes, which may require further assessment, but it does not automatically mandate a non-stress test. Additional evaluation and clinical judgment guide next steps rather than an automatic NST.