During an assessment, the nurse notices that an African American baby has a darker, slightly bluish patch about 5 by 7 cm on the buttocks and lower back. What should the nurse do?
1. Chart the presence of a Mongolian spot.
2. Ask the mother about the cause of the bruise.
3. Confer with the physician about the possibility of a bleeding tendency.
4. Call the Department of Social Services (DSS) to report this sign of abuse.
1
Explanation:
1. The nurse will chart the presence of a Mongolian spot, such as is observed in races with dark skin tones.
2. Asking the mother about the cause of the bruise reveals cultural ignorance in a less damaging manner than does calling DSS.
3. If choosing to confer with the physician, the nurse will reveal ignorance in culturally competent assessments.
4. 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.
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