A nurse is caring for a newborn diagnosed with erythema toxicum neonatorum. Which nursing action is most appropriate?
Bathe the newborn with hypoallergenic soap twice daily to reduce the rash.
Apply a thin layer of antibiotic ointment to prevent secondary infection.
Educate the parents that the condition is benign and requires no treatment.
Isolate the newborn to prevent spread to other infants.
Give antifungal treatments to the newborn.
The Correct Answer is C
A. Bathe the newborn with hypoallergenic soap twice daily to reduce the rash: Frequent bathing can disrupt the delicate acid mantle of the neonatal skin and cause irritation. Erythema toxicum is an idiopathic inflammatory response that does not respond to topical cleansing agents. Over-washing may exacerbate skin dryness without resolving the eosinophilic papules.
B. Apply a thin layer of antibiotic ointment to prevent secondary infection: This rash is a sterile condition characterized by eosinophilic infiltration rather than bacterial colonization. The use of prophylactic antibiotics is clinically unnecessary and may contribute to antimicrobial resistance. Topical ointments can also block pores and cause further cutaneous irritation.
C. Educate the parents that the condition is benign and requires no treatment: Erythema toxicum neonatorum is a self-limiting, non-pathological eruption common in healthy full-term infants. It typically resolves spontaneously within 7 to 14 days without any medical intervention. Reassurance is the primary nursing responsibility to alleviate parental anxiety.
D. Isolate the newborn to prevent spread to other infants: This condition is not infectious or transmissible, as it is an internal physiological reaction. Isolation protocols are reserved for contagious pathogens and would unnecessarily separate the infant from the mother. The rash does not pose a risk to the nursery population.
E. Give antifungal treatments to the newborn: The lesions of erythema toxicum are not fungal in origin and will not respond to antimycotic medications. Administering unnecessary drugs to a neonate carries risks of systemic side effects and toxicity. Proper diagnosis relies on recognizing the typical migratory pattern of the rash.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
A. Shoulder: The glenohumeral joint is a classic ball-and-socket synovial joint that offers the greatest range of motion in the body. It contains a joint capsule, synovial fluid, and articular cartilage to facilitate smooth movement. It is a primary example used in patient education regarding diarthrotic joints.
B. Wrist: The radiocarpal joint is a condyloid synovial joint that allows for flexion, extension, and side-to-side movement. It features a synovial membrane that secretes lubricating fluid to reduce friction between the carpal bones and the radius. This joint is highly susceptible to synovial inflammation in conditions like rheumatoid arthritis.
C. Skull: The bones of the skull are joined by sutures, which are categorized as fibrous, synarthrotic joints. These joints are designed for stability and protection of the brain rather than movement. They lack a joint cavity and synovial fluid, making them unsuitable for this specific teaching topic.
D. Spine: The joints between vertebral bodies are cartilaginous (symphyses), utilizing intervertebral discs for shock absorption and limited mobility. While the facet joints are technically synovial, the spine as a whole is generally classified by its cartilaginous components in basic education. It does not represent a typical "freely movable" synovial joint.
E. Ankle: The talocrural joint is a hinge-type synovial joint that facilitates dorsiflexion and plantarflexion of the foot. It is enclosed in a capsule and supported by ligaments, fitting the classic definition of a synovial articulation. It is a common site for synovial injuries such as sprains or effusions.
Correct Answer is D
Explanation
A. "Are you taking iron supplements?": Exogenous iron intake can cause a non-pathological darkening of the stool, which is a common side effect of supplementation. While this provides a potential benign explanation, the nurse must first rule out a life-threatening hemorrhage. This question is secondary to determining the physical characteristics of the stool.
B. "How frequent are the stools?": Frequency helps determine the severity of diarrhea or constipation but does not help differentiate between types of gastrointestinal bleeding. It provides data on bowel habits rather than the etiology of the abnormal color. The nurse's priority is to identify the presence of digested blood.
C. "Are others in your family similarly affected?": This question assesses for infectious etiologies or shared dietary exposures, which are less likely to present as isolated black stools. It does not provide immediate diagnostic information regarding the patient's current clinical stability. It is a lower-priority question during the initial assessment of melena.
D. "Is the consistency tarry (tar-like)?": Tarry, sticky, and foul-smelling black stools (melena) indicate an upper gastrointestinal bleed where blood has been digested by gastric acid. Non-tarry black stools are often caused by medications or diet. Establishing the consistency is the most critical step in identifying a potential medical emergency.
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