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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Reprimand the client about the potential damage that has occurred due to overexercising her body: Reprimanding is likely to increase feelings of guilt and shame, which can exacerbate the disorder. A supportive and empathetic approach is more beneficial.
B. Praise the client for looking at herself in a mirror: This could reinforce a negative preoccupation with body image, which is a significant aspect of anorexia nervosa. Encouraging healthy coping mechanisms is more appropriate.
C. Restrict the client from being weighed: While it is important to manage weight monitoring carefully, outright restriction without addressing the underlying issues can increase anxiety and resistance to treatment.
D. Ask the client to agree to talk to a nurse whenever she feels the urge to exercise: This helps the client develop healthier coping strategies and provides support in managing the urge to overexercise, promoting therapeutic engagement.
Correct Answer is ["0.3"]
Explanation
Convert weight from pounds to kilograms:
19pounds÷2.2=8.64kg
Calculate the total daily dose:
0.07mg/kg/day×8.64kg=0.6048mg/day
Divide the daily dose into two doses:
0.6048mg/day÷2=0.3024mg/dose
Round off the dose to two decimal places:
0.3024mg≈0.30mg
The maximum amount of medication per dose is 0.3 mg.
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