During assessment of a 2-month-old infant, the nurse notices a bluish-black discoloration over the lumbosacral area. Which action should the nurse take?
Document the findings in the record.
Report possible child abuse to protective services.
Gently rub the area with skin cream to promote healing.
Ask the mother about the discoloration.
The Correct Answer is A
A. Document the findings in the record – A bluish-black discoloration over the lumbosacral area is most likely a Mongolian spot, a benign congenital birthmark commonly seen in infants with darker skin tones. It does not require intervention, only documentation.
B. Report possible child abuse to protective services – Mongolian spots may resemble bruises, but they are not a sign of abuse. Reporting without further assessment is inappropriate.
C. Gently rub the area with skin cream to promote healing – Mongolian spots are not injuries and do not require treatment.
D. Ask the mother about the discoloration – While obtaining history is important, Mongolian spots are well-known benign findings that do not require further clarification from the parent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Applying restraints should not be the first approach in fall prevention and is associated with risks and ethical considerations.
Choice B: Accompanying residents during ambulation is a helpful practice but may not be feasible at all times. It's essential to promote independence when possible.
Choice C: Encouraging clients to wear rubber-soled shoes is an important fall prevention measure, as it can provide better traction and stability when walking.
Choice D: Leaving the hall lights on during the night may be helpful, but it is not the most critical intervention for fall prevention. Proper footwear and other measures should take precedence.
Correct Answer is D
Explanation
Choice A: A mechanical soft diet may still require some degree of chewing, which may be difficult for a client with no teeth. A pureed diet would be a more appropriate choice.
Choice B: A soft low-residue diet may include soft foods that require chewing, which could be challenging for a client with no teeth.
Choice C: A full liquid diet consists of liquids and foods that are in liquid form at room temperature, which may not provide adequate nutrition for the client.
Choice D: A pureed diet involves blending foods to a smooth consistency, making them suitable for clients with no teeth or difficulty chewing. It would be the most appropriate choice.
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