Answer to Question 1
Answer: C
Due to mandatory reporting laws, nurses must report all suspected cases of child abuse to the appropriate child protective services agency. It would not be appropriate at this time to discuss the findings with the infant's mother. The nurse does not know if the mother is aware of what is occurring and it would be best to have this further investigated. It would not be appropriate to discuss the findings with the other nurses as due to privacy regulations this information would be shared on a need-to-know basis.
Answer to Question 2
Answer: C
The most appropriate action for the nurse at this time is to assess the client's spiritual beliefs. The practice of cupping is generally practiced by many Asian cultures, as well as individuals who participate in holistic healing. Cupping is the act of placing a glass cup on the skin, and then using heat to create suction; often this is performed to promote blood flow and overall healing. The result of the procedure can be circular red welts or even dark bruising, which are often found along the individual's back. This treatment is not abusive in nature, but rather a form of healing.
The nurse applies a pulse oximeter sensor on the client’s finger.
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Use face cradle covers to prevent the client’s skin from touching the face cradle upholstery.
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