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 D

Explanation

A. Assess motor function in lower extremities: While important for overall neurological assessment, immediate post-repair monitoring of motor function is secondary to monitoring for signs of hydrocephalus (head circumference).
B. Maintain skin integrity: Essential for preventing infection but does not address the immediate post-surgical complication of hydrocephalus.
C. Monitor intake and output: Important for general post-operative care but does not address the immediate concern of monitoring for hydrocephalus.
D. Monitor head circumference: Following repair of a myelomeningocele, infants are at risk for developing hydrocephalus due to abnormal cerebrospinal fluid dynamics. Monitoring head circumference helps detect early signs of increased intracranial pressure, a common complication post-surgery.

A. Playing on the backyard swings and running around outside are exercises our child will really enjoy B. Three to four times a day we will perform chest therapy and postural drainage on our child C. A high protein, high calorie diet may need to be supplemented with a high-calorie formula D. Pancreatic enzymes will not be necessary if our child has a good appetite and regular bowel movements

Correct Answer is D

Explanation

A. Playing on the backyard swings and running around outside are exercises our child will really enjoy. Encouraging physical activity is beneficial as it helps with lung function and overall health.
B. Three to four times a day we will perform chest therapy and postural drainage on our child. This is correct and necessary to help clear mucus from the lungs.
C. A high protein, high-calorie diet may need to be supplemented with a high-calorie formula. This is important for meeting the nutritional needs of children with cystic fibrosis due to their higher caloric requirements.
D. Pancreatic enzymes will not be necessary if our child has a good appetite and regular bowel movements. This is incorrect; children with cystic fibrosis typically need pancreatic enzyme supplements with every meal and snack to aid digestion, regardless of appetite or bowel regularity.

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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?

Nursing Test Bank

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