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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because earphones are not used in the Rinne test. The Rinne test compares air conduction and bone conduction of sound using a tuning fork.
Choice B Reason: This is incorrect because electrodes are not used in the Rinne test. Electrodes are used in electroencephalography (EEG), which measures brain activity.
Choice C Reason: This is incorrect because a probe is not used in the Rinne test. A probe is used in tympanometry, which measures the pressure and mobility of the eardrum.
Choice D Reason: This is correct because a tuning fork is used in the Rinne test. The tuning fork is placed on the mastoid process behind the ear and then moved near the ear canal to compare the sound perception.

Correct Answer is D
Explanation
Choice A reason: This is incorrect because applying the medication when you are experiencing eye pain can be ineffective or harmful for treating open-angle glaucoma. Open-angle glaucoma is a chronic condition that causes increased pressure inside the eye and damage to the optic nerve, which can lead to vision loss. Eye pain is not a common symptom of open-angle glaucoma, but rather an indication of acute angle closure glaucoma, which is a medical emergency that requires immediate treatment. The nurse should instruct the client to apply the medication as prescribed, regardless of pain level, and seek medical attention if they experience severe eye pain, headache, nausea, or blurred vision.
Choice B reason: This is incorrect because using the medication only until the intraocular pressure returns to normal can cause recurrence or worsening of open-angle glaucoma. Intraocular pressure is the pressure inside
the eye that can affect eye health and vision. Normal intraocular pressure ranges from 10 to 21 mmHg, but it can vary depending on age, time of day, or other factors. The nurse should instruct the client to monitor their intraocular pressure regularly and report any changes to their provider, but not to stop using
the medication without consulting their provider first.
Choice C reason: This is incorrect because using the medication for approximately 10 days, then gradually tapering off can cause rebound or adverse effects of open-angle glaucoma. The medication for open-angle glaucoma can be either beta-blockers, such as timolol, or cholinergic agents, such as pilocarpine, which work by reducing fluid production or increasing fluid drainage in the eye. The nurse should instruct the client to follow their provider's instructions on how long and how much to use the medication and not to change or discontinue it abruptly without their provider's approval.
Choice D reason: This is correct because applying the medication on a regular schedule for the rest of your life can help control and prevent the progression of open-angle glaucoma. Open-angle glaucoma is a lifelong condition that requires consistent and continuous treatment to maintain normal intraocular pressure and prevent vision loss. The nurse should instruct the client to apply the medication at the same time every day and not to miss or skip any doses. The nurse should also teach the client how to store, handle, and administer the medication properly and safely.
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