During assessment of a 2-month-old infant, the nurse notices a bluish-black discoloration over the lumbosacral area. Which action should the nurse take?
Document the findings in the record.
Report possible child abuse to protective services.
Gently rub the area with skin cream to promote healing.
Ask the mother about the discoloration.
The Correct Answer is A
A. Document the findings in the record – A bluish-black discoloration over the lumbosacral area is most likely a Mongolian spot, a benign congenital birthmark commonly seen in infants with darker skin tones. It does not require intervention, only documentation.
B. Report possible child abuse to protective services – Mongolian spots may resemble bruises, but they are not a sign of abuse. Reporting without further assessment is inappropriate.
C. Gently rub the area with skin cream to promote healing – Mongolian spots are not injuries and do not require treatment.
D. Ask the mother about the discoloration – While obtaining history is important, Mongolian spots are well-known benign findings that do not require further clarification from the parent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Broccoli is not typically restricted before a gallbladder ultrasound.
Choice B: Instructing the client to avoid consuming a milkshake the night before the test is important because a fatty meal can affect gallbladder contraction and visualization during the ultrasound.
Choice C: A garden salad is not typically restricted before a gallbladder ultrasound.
Choice D: Coffee is not typically restricted before a gallbladder ultrasound.
Correct Answer is ["A","C"]
Explanation
Choice A: Cooked cereal can be used as part of a gastrostomy tube feeding regimen for clients who require enteral nutrition.
Choice B: Lettuce is not typically used in gastrostomy tube feedings as it may not be well-tolerated in liquid form.
Choice C: Clear fat-free broth can be used as part of a gastrostomy tube feeding regimen for clients who require enteral nutrition.
Choice D: Brussels sprouts and nuts are not typically used in gastrostomy tube feedings as they may not be well-tolerated in liquid form.
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