A nurse is performing a skin assessment on a client who has dark skin.
Which of the following locations on the client’s body should the nurse observe to assess for cyanosis?
Area of trauma.
Sacrum.
Shoulders.
Palms of the hands.
The Correct Answer is D
Cyanosis is a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. It is more difficult to detect in people who have dark skin, so the nurse should look for cyanosis in areas where the skin is thinner and the blood supply is richer, such as the palms of the hands, the lips, the gums, and around the eyes.
These areas are less affected by melanin, the pigment that gives skin its color.
Choice A is wrong because an area of trauma may have bruising or inflammation that can mask cyanosis.
Choice B is wrong because the sacrum is not a good site to assess for cyanosis in any skin tone, as it is prone to pressure ulcers and poor circulation.
Choice C is wrong because the shoulders are not a mucous membrane and may have more melanin than other areas of the body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
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The correct answer is choice c. Contractions.
Choice A rationale:
Epigastric pain is not a common complication following an amniocentesis. It is more often associated with conditions like preeclampsia or gastrointestinal issues.
Choice B rationale:
Hypertension is not directly related to amniocentesis. It is more commonly associated with conditions like preeclampsia or chronic hypertension in pregnancy.
Choice C rationale:
Contractions are a significant complication to monitor for after an amniocentesis, especially at 33 weeks of gestation. The procedure can sometimes induce preterm labor.
Choice D rationale:
Vomiting is not a typical complication following an amniocentesis. It may occur due to other unrelated reasons but is not directly linked to the procedure.
Correct Answer is D
Explanation
The correct answer is choice D, spotting.
Placenta previa is a condition where the placenta implants in the lower part of the uterus, partly or completely covering the cervical opening.
This can cause painless, bright red vaginal bleeding, usually in the third trimester.
Spotting is a sign of placenta previa and should be reported to the provider immediately.
Choice A is wrong because nausea is not a specific finding of placenta previa.
Nausea can occur in normal pregnancy or in other conditions such as hyperemesis gravidarum or preeclampsia.
Choice B is wrong because polyhydramnios is not a finding of placenta previa.
Polyhydramnios is a condition where there is too much amniotic fluid in the uterus, which can cause complications such as preterm labor, cord prolapse, or fetal malformations.
Choice C is wrong because uterine tenderness is not a finding of placenta previa.
Uterine tenderness is a sign of abruptio placentae, which is a condition where the placenta separates from the uterine wall before delivery.
This can cause severe abdominal pain, dark red vaginal bleeding, and fetal distress.
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