A nurse in a clinic is caring for a group of infants. Which of the following findings should the nurse report as a possible indication of physical maltreatment?
A hemangioma on the infant's torso
A burn with splash marks on the lower right leg
A large, irregular, brownish-blue area on the infant's buttock
An abrasion on the back of the infant's arm
The Correct Answer is B
Rationale:
A) A hemangioma is a benign vascular tumor commonly found in infants and is not indicative of physical maltreatment.
B) A burn with splash marks, especially in a patterned distribution, raises suspicion of physical abuse and should be reported immediately for further evaluation.
C) A large, irregular, brownish-blue area on the infant's buttock may indicate bruising, but further assessment is needed to determine the cause.
D) An abrasion on the back of the infant's arm may be due to accidental injury and does not necessarily indicate physical maltreatment, although it warrants further assessment and documentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A) Using an automated lancet device provides a controlled and consistent depth of puncture for the heel stick, minimizing discomfort and risk of injury.
B) Applying limb restraints is unnecessary and could cause distress to the infant.
C) Puncturing the heel at the inner aspect may not be the appropriate site for the heel stick.
D) Cleansing the area with povidone iodine is not necessary for a routine heel stick procedure.
Correct Answer is C
Explanation
Rationale:
A) A tepid bath may cause shivering, which can increase the temperature.
B) Aspirin is contraindicated in children due to the risk of Reye's syndrome.
C) Removing the toddler's extra clothing can help lower the body temperature by allowing heat to escape through the skin.
D) Cooling blankets are typically reserved for severe cases of hyperthermia and may not be appropriate or safe for use in a toddler with a moderately elevated temperature.
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