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.
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.
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