When preforming 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
Document the findings in the electronic health record
Report parents to Child Protective Services
Notify the healthcare provider
The Correct Answer is B
A. Clotting studies are unnecessary as Mongolian spots are not related to a bleeding disorder.
B. Mongolian spots are a normal finding in newborns with increased melanin deposition in the skin. The nurse should document the finding to differentiate it from potential bruising in future assessments.
C. Reporting parents to Child Protective Services is inappropriate because Mongolian spots are congenital, not signs of abuse.
D. Notifying the healthcare provider is unnecessary as Mongolian spots are a normal variation, not a medical concern.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Documenting findings is important but not the priority action when the uterus is boggy.
B. Notifying the provider is necessary if fundal massage is ineffective, but the nurse should first attempt massage.
C. Massaging the fundus helps stimulate uterine contractions, which is the first-line intervention for a boggy uterus.
D. Oxytocin (Pitocin) is often used to maintain uterine tone, but fundal massage is the initial intervention.
Correct Answer is B
Explanation
A. Clotting studies are unnecessary as Mongolian spots are not related to a bleeding disorder.
B. Mongolian spots are a normal finding in newborns with increased melanin deposition in the skin. The nurse should document the finding to differentiate it from potential bruising in future assessments.
C. Reporting parents to Child Protective Services is inappropriate because Mongolian spots are congenital, not signs of abuse.
D. Notifying the healthcare provider is unnecessary as Mongolian spots are a normal variation, not a medical concern.
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