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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A: When a reflex response is not elicited, it is important to proceed with testing other reflexes later in the exam to assess the overall neurological status. A single absence of a reflex may not be indicative of a problem, so further assessment is needed.

Choice B: Distracting the client by instructing him to pull on his fingers is not an appropriate action when assessing reflexes.

Choice C: Instructing the client to see a neurologist as soon as possible based solely on the absence of one reflex would be premature. Further assessment is needed to determine the significance.

Choice D: Recording the patellar reflex as a zero without further assessment would not provide a comprehensive evaluation of the client's reflexes.

A. Apply compression stockings before ambulation. B. Soak feet to soften nails before trimming. C. Keep legs dependent to promote blood flow. D. Medicate inflamed skin areas with an antibiotic ointment.

Correct Answer is A

Explanation

Choice A: Applying compression stockings before ambulation is a key aspect of self-care for a client with chronic venous insufficiency. Compression stockings help improve venous return and reduce edema.

Choice B: Soaking feet to soften nails before trimming is not a specific intervention for chronic venous insufficiency and should be done with caution in individuals with open ulcers.

Choice C: Keeping legs dependent to promote blood flow is not advisable in chronic venous insufficiency, as it can worsen venous pooling and edema.

Choice D: Medicating inflamed skin areas with an antibiotic ointment may be part of wound care but does not address the primary intervention of using compression stockings for chronic venous insufficiency.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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