While assessing a 10-month-old African American infant, the nurse notices that the sclerae have a yellowish tint. Which organ system should the nurse further evaluate to determine an ongoing disease process?
1. Cardiac
2. Respiratory
3. Gastrointestinal
4. Genitourinary
Correct Answer: 3
Rationale: This infant's sclerae are showing signs of jaundice, which most likely is secondary to a failure or malfunction of the liver in the gastrointestinal system. Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system. Tenting of the skin and dry mucous membranes could be a sign of dehydration, and edema could be a sign of fluid overload. Both of these conditions could be secondary to problems with functioning of the genitourinary system.
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