A nurse is assessing an older adult client’s mouth.

The nurse should identify that which of the following is an expected variation for this client?

White patches on the tongue

Bleeding of the gums

Darkening of the mucosa

Red spots on the hard palate.

Answer and Explanation

The Correct Answer is D

Darkening of the mucosa. This is an expected variation for an older adult client because the melanin production increases with age.

Some possible explanations for the other choices are:

• Choice A. White patches on the tongue could indicate candidiasis, an oral fungal infection.

• Choice B. Bleeding of the gums could indicate gingivitis, periodontitis, or vitamin C deficiency.

• Choice C. Red spots on the hard palate could indicate petechiae, which are small hemorrhages caused by trauma, infection, or bleeding disorders.

Normal ranges for oral mucosa color vary depending on the skin tone and ethnicity of the client. Generally, the oral mucosa should be pink and moist without lesions or discolorations.

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Correct Answer is A

Explanation

Monitor for signs of jaundice.A cephalohematoma is a collection of blood under the scalp that occurs due to trauma or pressure during delivery.It may increase the risk of jaundice in the newborn due to the breakdown of red blood cells and the release of bilirubin.Jaundice is a condition that causes yellowing of the skin and eyes due to high levels of bilirubin in the blood.Monitoring for signs of jaundice is important to prevent complications such as brain damage or kernicterus.

Apply pressure dressing over the area.This is wrong because applying pressure may increase the bleeding and cause more damage to the scalp and skull.A cephalohematoma does not require any treatment and usually resolves on its own within weeks or months.

Administer antibiotics as prescribed.This is wrong because antibiotics are not indicated for a cephalohematoma unless there is evidence of infection.Infection is a rare complication that may lead to osteomyelitis or meningitis.Antibiotics should be used only if prescribed by a doctor based on clinical signs and laboratory tests.

Elevate the head of the bed.This is wrong because elevating the head of the bed may not have any effect on a cephalohematoma.It may also cause discomfort or compromise the airway of the newborn.The position of the baby should be adjusted according to their comfort and safety.

A. Place the newborn on the mother’s chest after delivery. B. Wrap the newborn in a blanket and hand to the father. C. Place the newborn in an isolette next to the mother’s bed. D. Dress the newborn in a gown and hat before giving to the mother.

Correct Answer is A

Explanation

Place the newborn on the mother’s chest after delivery.This is because skin-to-skin contact between mother and baby promotes bonding and attachment, which are essential for the baby’s emotional and psychological development.Skin-to-skin contact also helps regulate the baby’s body temperature, heart rate, breathing and blood sugar levels.

Choice B is wrong because wrapping the newborn in a blanket reduces the skin-to-skin contact and may interfere with the bonding process.The father can also bond with the baby by holding him or her against his own skin.

Choice C is wrong because placing the newborn in an isolette separates the baby from the mother and prevents close interaction and communication.The baby may feel insecure and isolated in an isolette.

Choice D is wrong because dressing the newborn in a gown and hat also reduces the skin-to-skin contact and may delay the initiation of breastfeeding.The baby may also lose more heat through clothing than through direct contact with the mother’s body.

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A nurse is assessing an older adult client’s mouth. The nurse should identify that which of the following is an expected variation for this client?

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A nurse is assessing an older adult client’s mouth. The nurse should identify that which of the following is an expected variation for this client?

A nurse is assessing an older adult client’s mouth.

The nurse should identify that which of the following is an expected variation for this client?