What if nurse observes irregular dark blue pigmentation


Problem: When collecting data on a 4-month-old client with gastroenteritis, the nurse observes an irregular area of dark blue pigmentation on the client's sacral area. The nurse should first:

1. Determine whether this finding is normal for an infant of the client's racial background

2. Ask the client's parent whether the child has shown any tendency toward bleeding

3. Report the finding to the charge nurse as evidence of possible child abuse

4. Apply gentle pressure to the area to check for tenderness

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