An Asian family arrives with their newborn for a well visit. When assessing the infant, the nurse observes the following skin irregularity. What is the nurse's priority action?

Notify child protective services

Record the finding

Notify the healthcare provider

Interview the clients about the injury

Answer and Explanation

The Correct Answer is B

Choice A Reason: Notifying child protective services is not the priority action, as it is not indicated by the skin irregularity. The skin irregularity is most likely a Mongolian spot, which is a benign, bluish-gray or purple patch of pigmentation that is common in infants of Asian, African, or Hispanic descent. It is not a sign of abuse or injury, but rather a normal variation of skin color.

Choice B Reason: This is the correct choice. Recording the finding is the priority action, as it documents the presence and location of the Mongolian spot and prevents confusion or misdiagnosis in the future. The Mongolian spot usually fades by age 2 to 4 years, but it may persist into adulthood.

Choice C Reason: Notifying the healthcare provider is not the priority action, as it is not necessary for the skin irregularity. The skin irregularity is not a cause for concern or intervention, but rather a normal variation of skin color.

Choice D Reason: Interviewing the clients about the injury is not the priority action, as it is not appropriate for the skin irregularity. The skin irregularity is not an injury, but rather a normal variation of skin color. Interviewing the clients about it may imply suspicion or accusation of abuse, which can damage the nurse-client relationship and trust.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A Reason: This is correct because the patient's Glasgow Coma Scale score is 9. The Glasgow Coma Scale is a tool that assesses the level of consciousness of a patient with a head injury by measuring three parameters: eye opening, verbal response, and motor response. The patient's eye opening score is 3 (opens eyes to verbal command), verbal response score is 4 (confused speech), and motor response score is 2 (withdraws from pain). The total score is the sum of these three scores, which is 9.

Choice B Reason: This is incorrect because the patient's Glasgow Coma Scale score is not 11. To get a score of 11, the patient would need to have a higher motor response score, such as 4 (withdraws to touch) or 5 (localizes to pain).

Choice C Reason: This is incorrect because the patient's Glasgow Coma Scale score is not 15. To get a score of 15, the patient would need to have the highest scores for all three parameters, such as 4 (opens eyes spontaneously), 5 (oriented speech), and 6 (obeys commands).

Choice D Reason: This is incorrect because the patient's Glasgow Coma Scale score is not 13. To get a score of 13, the patient would need to have a higher verbal response score, such as 5 (oriented speech).

A. Heart rate 122/min B. Urinary output 25 ml/hr C. Pain of 6 on a scale of 0 to 10 D. Difficulty swallowing

Correct Answer is D

Explanation

Choice A Reason: A heart rate of 122/min is elevated, but not life-threatening. It could be due to pain, anxiety, dehydration, or infection.

Choice B Reason: A urinary output of 25 ml/hr is low, but not critical. It could indicate fluid loss, kidney damage, or inadequate fluid resuscitation.

Choice C Reason: A pain level of 6 on a scale of 0 to 10 is moderate, but not severe. It could be managed with analgesics and non-pharmacological interventions.

Choice D Reason: This is the correct answer because difficulty swallowing can indicate airway obstruction, inhalation injury, or edema of the throat. It can compromise breathing and require immediate intervention.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

An Asian family arrives with their newborn for a well visit. When assessing the infant, the nurse observes the following skin irregularity. What is the nurse's priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with a head injury opens his eyes to verbal stimulation, shouts out when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. How would the nurse record the patient's Glasgow Coma Scale score?

Correct Answer is A

Explanation

A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider?

Correct Answer is D

Explanation

A nurse is caring for a client who is experiencing Cushing's Triad following a subdural hematoma. Which of the following manifestations will the nurse expect to find? (Select all that apply.)

A nurse caring for a client with acute peritonitis reviews the physician's orders. The orders include an NPO diet, insertion of a nasogastric tube set to low intermittent suction, and IV fluids at 50 mL per hour. When asked why he will need the NG tube, what is the nurse's best reply?

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence?

When providing information to a client in the rehabilitative phase of a burn injury, which of the following will the nurse identify as the goal?

The results of a client's audiogram indicate that the client has hearing at 15 decibels (dB). What action should the nurse take when communicating to the client?

After completing a neurological assessment, the nurse documents that the client is stuporous. Which of the following describes this level of consciousness?

A nurse provides education to a client recently diagnosed with macular degeneration. Which of the following statements made by the client requires reinforcement of education by the nurse?

A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?