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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Assess motor function in lower extremities: While important for overall neurological assessment, immediate post-repair monitoring of motor function is secondary to monitoring for signs of hydrocephalus (head circumference).
B. Maintain skin integrity: Essential for preventing infection but does not address the immediate post-surgical complication of hydrocephalus.
C. Monitor intake and output: Important for general post-operative care but does not address the immediate concern of monitoring for hydrocephalus.
D. Monitor head circumference: Following repair of a myelomeningocele, infants are at risk for developing hydrocephalus due to abnormal cerebrospinal fluid dynamics. Monitoring head circumference helps detect early signs of increased intracranial pressure, a common complication post-surgery.
Correct Answer is B
Explanation
A. Hypoplastic heart syndrome: Characterized by underdevelopment of the left side of the heart, not mixing of blood.
B. Atrioventricular canal defect: An atrioventricular canal defect allows oxygenated and deoxygenated blood to mix due to the presence of a common atrioventricular valve and defects in the atrial and ventricular septa. This defect results in a mixture of oxygenated and deoxygenated blood, which can cause varying levels of oxygenation in the blood delivered to the body.
C. Tetralogy of Fallot: Involves a ventricular septal defect leading to right-to-left shunting, but not a direct mixing of oxygenated and deoxygenated blood.
D. Coarctation of the aorta: Involves narrowing of the aorta, not mixing of oxygenated and deoxygenated blood.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.