During the assessment, the nurse notices that a Black baby has a darker, slightly bluish-hued patch about 5 × 7 cm on the buttocks and lower back. What is the nurse's next action?
1. Ask the mother about the cause of the bruise.
2. Call the Department of Social Services (DSS) to report this as a sign of abuse.
3. Confer with the physician the possibility of a bleeding tendency.
4. Chart the presence of a Mongolian spot.
4
Rationale 1: Asking the mother about the cause of the bruise reveals cultural ignorance.
Rationale 2: 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.
Rationale 3: In choosing to confer with the physician, the nurse will reveal ignorance in culturally competent assessments.
Rationale 4: The nurse will chart the presence of a Mongolian spot, as this may be observed in races with dark skin tones.
Global Rationale:
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