During the assessment, the nurse notices that a black baby has a ...

[Ebrown]

During the assessment, the nurse notices that a black baby has a darker, slightly bluish-hued patch about 5 cm by 7 cm on the buttocks and lower back. What is the nurse's next action?
 
  1. Call the Department of Social Services (DSS) to report this sign of abuse.
  2. Confer with the physician about the possibility of a bleeding tendency.
  3. Ask the mother about the cause of the bruise.
  4. Chart the presence of a Mongolian spot.

Question 2

Which IV solution would be best to treat a client who is experiencing a postpartum hemorrhage?
 
  a. D5 1/2 NS c. 1/4 NS
  b. D5W d. LR

[smrtceo]

Answer to Question 1

4
Rationale:
1. The nurse who calls the DSS to report this patch as a sign of abuse will reveal ignorance in culturally competent assessments and possibly provoke harassment of the family.
2. If choosing to confer with the physician, the nurse will reveal ignorance in culturally competent assessments.
3. Asking the mother about the cause of the bruise reveals cultural ignorance in a less damaging manner than does calling DSS.
4. The nurse will chart the presence of a Mongolian spot, such as is observed in races with dark skin tones.

Answer to Question 2

D
LR and 0.9 normal saline are the two volume expanders used to treat hemorrhage. The reason LR is the most commonly used is that metabolic acidosis occurs when hemorrhage causes shock and the lactate ions from LR are converted to bicarbonate.

[Ebrown]

Excellent

[isabelt_18]

Gracias!