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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A: Bread is generally considered a suitable food choice for individuals with cholelithiasis and is not typically associated with exacerbating symptoms or gallstone formation.

Choice B: Beef broth is a liquid and does not contain the same types of fats and cholesterol that can contribute to gallstone formation. It is not typically a concern for individuals with cholelithiasis.

Choice C: Ketchup is often high in sugar and can be made with vinegar, which may exacerbate symptoms in some individuals with cholelithiasis. It is advisable to omit or limit foods high in sugar and vinegar-based condiments.

Choice D: Ice cream, while high in fat, is generally tolerated by most individuals with cholelithiasis unless they experience specific dietary sensitivities. It is not typically recommended to omit ice cream from the diet unless advised by a healthcare provider.

A. Oranges B. Fortified milk. C. Bananas D. Apple juice.

Correct Answer is B

Explanation

Choice A: Oranges are a good source of vitamin C, which is important for overall health, but they are not the primary dietary source for preventing rickets.

Choice B: Fortified milk is the best dietary source for preventing rickets because it is enriched with vitamin D, which is essential for calcium absorption and bone health. Vitamin D helps prevent rickets by promoting the absorption of calcium and phosphate in the body, which are necessary for proper bone development.

Choice C: Bananas are a good source of potassium but are not a primary dietary source for preventing rickets.

Choice D: Apple juice is not a primary dietary source for preventing rickets. While it may provide some vitamins and minerals, it is not directly associated with preventing this condition.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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