Author Question: The nurse is caring for a client with dark skin and needs to assess the skin for jaundice. Which ... (Read 145 times)

plus1 · **on:** Jun 25, 2018

The nurse is caring for a client with dark skin and needs to assess the skin for jaundice. Which action would be appropriate for the nurse in this situation?

1. Use a bright lamp and a magnifying glass.
2. Document unable to assess for skin changes.
3. Assess the skin the same way you would inspect a client with lighter skin.
4. Inspect the lips, oral mucosa, sclera, conjunctivae, and palms.

Question 2

The pediatric nurse conducts a follow-up phone call for a mother who was discharged with her newborn several days ago. The mother tells the nurse that she thinks her newborn is jaundice.

Which question by the nurse will help to support this mother's statement?
1. Does your baby have tiny, white facial bumps?
2. Does your baby's skin and mucous membranes have a yellowish color?
3. Does your baby have irregular red patches on the back of the neck?
4. Does your baby have dark spots on the area above the buttock?

samiel-sayed · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 4

Changes in skin color may be difficult to discover when assessing clients with dark skin. The nurse should inspect areas of the body with less pigmentation such as the lips, oral mucosa, sclera, palms of the hand, and conjunctivae. A bright light may assist the nurse, but the nurse should inspect the client's lips, oral mucosa, sclera, conjunctivae, and palms when assessing for jaundice. It is not appropriate to document that the nurse is unable to assess the client for jaundice. The nurse will not find it as useful to assess the client with darker skin in the same way that the nurse would assess the client with lighter skin. The nurse should inspect areas of the body with less pigmentation such as the lips, oral mucosa, sclera, palms of the hand, and conjunctivae.

Answer to Question 2

Correct Answer: 2
Yellowing of skin and mucous membranes in an infant who is 3-4 days old is a temporary form of jaundice called physiological jaundice, but may require treatment with fluids and phototherapy. Milia are tiny, white facial papules due to sebum and will resolve within a few weeks of birth. Vascular markings are also called stork bites and may be located on the back of the neck. Harmless skin markings requiring no intervention include gray, blue, or purple spots (Mongolian spots) on the buttocks or sacral area.