When performing an initial assessment on a full-term infant whose parents are Asian, the nurse notes a blue-gray discoloration across the sacrum of the newborn. What is the most appropriate action for the nurse to take?

Review clotting studies lab report

Notify the healthcare provider

Document the findings in the electronic health record

Report parents to Child Protective Services

Answer and Explanation

The Correct Answer is C

A. Review clotting studies lab report: Not relevant to the assessment finding of a blue-gray discoloration.
B. Notify the healthcare provider: Unnecessary unless there are other concerning clinical findings.
C. Document the findings in the electronic health record: A blue-gray discoloration across the sacrum is likely a Mongolian spot, a benign condition more commonly seen in infants of Asian, African, Native American, and Hispanic descent. Documenting this finding in the electronic health record ensures accurate and comprehensive medical documentation without unnecessary interventions.
D. Report parents to Child Protective Services: Inappropriate as this finding is a benign condition common among certain ethnic groups and not indicative of abuse.

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Correct Answer is ["A","C","D","F"]

Explanation

A. Provide the caregiver with resources in the community for support: Ensures the caregiver has access to additional help and knowledge about asthma management.
B. Provide the child with a pamphlet on how to use an inhaler: While education for the child is important, at 5 years old, the ability to manage an inhaler independently may not be developmentally appropriate.
C. Refer the caregiver to the asthma educator: Specialized instruction can enhance the caregiver's understanding of asthma management.
D. Ask the caregiver, "what worries you about your child?": Understanding concerns helps tailor education and support to address specific needs.
E. Teach the child how to use the inhaler: Similar to B, teaching the child directly to use the inhaler without supervision may not be feasible at this age.
F. Provide information on child development: Educates the caregiver about realistic expectations regarding the child's ability to manage asthma independently.

A. Handwashing B. Gardasil injection C. Penicillin D. Use of barrier protection E. Perineal care of genital lesions

Correct Answer is ["A","D","E"]

Explanation

A. Handwashing. Good hygiene is important to prevent the spread of the virus, especially after touching the lesions.
B. Gardasil injection. Gardasil is a vaccine for HPV, not HSV. It is not relevant for the management of herpes.
C. Penicillin. Penicillin is not effective against viral infections like herpes; antiviral medications such as acyclovir are used for treatment.
D. Use of barrier protection. Barrier methods such as condoms are crucial in reducing the risk of transmission of HSV-2 to sexual partners.
E. Perineal care of genital lesions. Proper care of lesions can help reduce discomfort and prevent secondary infections.

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When performing an initial assessment on a full-term infant whose parents are Asian, the nurse notes a blue-gray discoloration across the sacrum of the newborn. What is the most appropriate action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute pediatric unit is assessing a 5-year-old child following an asthma event. The child's caregiver expects the child to use an inhaler without supervision. The nurse can apply which of the following interventions as protective factors for the child? (Select All that Apply.)

Correct Answer is ["A","C","D","F"]

Explanation

A 19-year-old goes to Planned Parenthood clinic with complaints of painful lesions, fever, headache, and vaginal discharge. After testing she is diagnosed with Herpes simplex virus type 2. What education should the nurse include in a teaching plan? (Select All that Apply.)

Correct Answer is ["A","D","E"]

Explanation

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