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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The newborn with a heart rate of 154 beats/minute. This is within the normal range for a newborn, which is between 120-160 beats per minute.
B. The newborn with a respiratory rate of 72 breaths/minute. This is abnormal; the normal respiratory rate for a newborn is between 30-60 breaths per minute. A rate of 72 could indicate respiratory distress and requires prompt evaluation.
C. The newborn with a red raised capillary hemangioma on the left forearm. Capillary hemangiomas are common, benign vascular tumors that typically do not require immediate intervention.
D. The newborn with whitish, hardened nodules on the gums of the mouth. These are likely Epstein pearls, which are harmless cysts often seen in newborns and typically resolve on their own.
Correct Answer is D
Explanation
A. Use physical restraints during severe outbursts to ensure safety: Restraints should only be used as a last resort and are not an effective or ethical primary strategy for managing behavior in children with ODD.
B. Assign daily chores that are challenging to encourage discipline: Assigning overly challenging chores may lead to frustration and non-compliance, exacerbating behavioral issues rather than helping.
C. Encourage solitary play to reduce social stressors: Isolating the child may worsen feelings of exclusion and does not address the need for social skills development and appropriate behavior in social contexts.
D. Put into practice consistent consequences for rule-breaking behavior: Consistency in consequences helps the child understand boundaries and the importance of following rules, which is crucial for managing behavior in ODD.
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