Hesi Cat
Hesi Cat ( 79 Questions)
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?
Documenting the findings in the record is appropriate, but it should not be the only action taken when there is an unusual discoloration on an infant's skin.
Reporting possible child abuse to protective services should be done if there are strong suspicions or evidence of abuse. However, a bluish-black discoloration alone may not necessarily indicate abuse, so further assessment and information gathering are needed.
Gently rubbing the area with skin cream is not appropriate without a clear understanding of the cause of the discoloration. It's important to first assess and gather information.
Asking the mother about the discoloration is the most appropriate initial action. It's important to gather information about the infant's history, potential birthmarks, or other factors that could contribute to the discoloration.
Choice A: Documenting the findings in the record is appropriate, but it should not be the only action taken when there is an unusual discoloration on an infant's skin.
Choice B: Reporting possible child abuse to protective services should be done if there are strong suspicions or evidence of abuse. However, a bluish-black discoloration alone may not necessarily indicate abuse, so further assessment and information gathering are needed.
Choice C: Gently rubbing the area with skin cream is not appropriate without a clear understanding of the cause of the discoloration. It's important to first assess and gather information.
Choice D: Asking the mother about the discoloration is the most appropriate initial action. It's important to gather information about the infant's history, potential birthmarks, or other factors that could contribute to the discoloration.