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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Limit alcohol and caffeine intake. This is important for bone health and overall well-being during menopause, especially since alcohol and caffeine can affect bone density.
B. Decreasing the intake of dairy products. While calcium intake is important, decreasing dairy intake is not a recommended strategy during menopause unless there are specific dietary restrictions or intolerances.
C. Performing regular weight-bearing exercises. This is important for maintaining bone density but may not be the most important measure compared to limiting alcohol and caffeine intake.
D. Taking vitamin E and B complex vitamin supplements. While vitamins are important, they are not as critical as lifestyle measures like limiting alcohol and caffeine.

A. Circumoral cyanosis B. Tachycardia C. Elevated diastolic blood pressure D. Bradycardia E. Bounding peripheral pulses F. Continuous murmur G. Narrow pulse pressure

Correct Answer is ["B","E","F"]

Explanation

A. Circumoral cyanosis. This can occur but is less specific for PDA and more related to general issues with oxygenation.
B. Tachycardia. PDA can lead to increased heart rate as the heart works harder to manage the increased blood flow.
C. Elevated diastolic blood pressure. PDA usually causes a decrease in diastolic pressure, not an increase.
D. Bradycardia. Bradycardia is not typically associated with PDA.
E. Bounding peripheral pulses. PDA allows more blood to flow into the systemic circulation, leading to stronger pulses.
F. Continuous murmur. PDA typically causes a continuous "machine-like" murmur because of the continuous flow of blood from the aorta to the pulmonary artery.
G. Narrow pulse pressure. PDA often causes a wide pulse pressure, not a narrow one.

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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?

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When teaching a menopausal woman who chooses not to use hormone therapy what self-care measure is most important to include?

Correct Answer is A

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