NCLEX PN Exam Practice Test Related

Review NCLEX PN Exam Practice Test related questions and content

The nurse is monitoring a newborn with skin discoloration in the buttock and lumbar area. Which action by the nurse is appropriate?
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  • A. Check the newborn's hemoglobin, hematocrit, and platelet levels
  • B. Measure and document the size and location of the markings
  • C. Notify the registered nurse of the markings immediately
  • D. Review the delivery record for evidence of a traumatic birth
Correct Answer: B

Rationale: Skin discoloration in the buttock and lumbar area of a newborn is often due to Mongolian spots (also called congenital dermal melanocytosis). These are benign, flat, bluish-gray patches typically found on the lower back or buttocks. They are more common in infants with darker skin tones and are not harmful, but they can be mistaken for bruises, which raises concern for abuse later on.
The appropriate nursing action is to measure and document the size, shape, and location of the spots in the medical record. This ensures that there is a clear, dated record of the findings to avoid confusion in the future.