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 A,B,D,C
Explanation
Choice A: Retracting the needle into the syringe should be done before safely disposing of the syringe.
Choice B: Placing the syringe in a puncture-resistant container is the second step to ensure safe disposal of sharp objects.
Choice C: Applying an adhesive bandage over the injection site is the final step to address the bleeding and protect the site.
Choice D: Removing disposable exam gloves is the next step to prevent any contamination.
Correct Answer is B
Explanation
Choice A: This is important for the client's overall health but is not the most immediate priority in managing diabetes.
Choice B: The most important intervention for this client is to address lifestyle factors that contribute to diabetes and overall health. Weight loss and dietary changes are key components of managing type 2 diabetes. The client's weight is significantly above a healthy range, and losing 2 pounds (1 kg) per week is a reasonable and safe goal.
Choice C: Encouraging family members to be tested for diabetes is relevant but does not directly address the client's own management of the condition.
Choice D: Determining the client's feelings about the diagnosis is important for emotional support but does not directly address the client's physical health and diabetes management.
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