1. A Hispanic client, who is gravida 5, para 4, notices small bluish marks with indistinct edges on her newborn's buttocks and lower back. The most appropriate response by the nurse would be to:
1. A Hispanic client, who is gravida 5, para 4, notices small bluish marks with indistinct edges on her newborn's buttocks and lower back. The most appropriate response by the nurse would be to:
. Call child protective services to remove the baby from an abusive environment.
. Reassure her that it is a normal finding in darker skinned infants.
. Measure the size of the mark and document it.
. Call the physician to report the finding.
Test-Taking Tip
Mongolian spots are sometimes mistaken for bruises, but are normal findings. Eliminate the alternatives that suggest it is abnormal.
Content Area: Child Health, Newborn; Integrated Process: Nursing Process Implementation; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
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Answer 1 is incorrect because the mark is not a bruise or a sign of abuse, and does not need to be reported to child protective services. Answer 2 is correct because the mark is a mongolian spot, a normal variant in darker-skinned infants. Answer 3 is incorrect because the size of the mongolian spot(s) is not usually documented since they are normal, and do not change in size during hospitalization. Answer 4 is incorrect because mongolian spots are normal. There is no need to call and report to the physician.