A nurse is collecting data from a newborn who was born 24 hr ago. Which of the following images should the nurse identify as an indication that the newborn has erythema toxicum?
A
B
C
The Correct Answer is B
Rationale:
A. This image shows a newborn with normal skin tone and no visible skin lesions. There are no signs of erythema, pustules, or macules that would suggest erythema toxicum.
B. This image displays multiple small, erythematous macules and papules, especially on the face. These are classic signs of erythema toxicum neonatorum, a common and harmless rash seen in the first days of life.
C. The newborn in this image has generally red skin, which could be due to normal newborn circulation changes or mild erythema, but it lacks the distinctive papular or pustular rash pattern seen in erythema toxicum.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Seeking clarification: Seeking clarification involves asking the client to explain something they have already said to ensure mutual understanding. It usually occurs in response to ambiguous or unclear statements, not as an initial, open-ended invitation to speak.
B. Reflecting: Reflecting is a technique in which the nurse restates the client’s feelings or thoughts to encourage deeper exploration. The nurse in this case is not restating anything but is instead prompting the client to share independently.
C. Focusing: Focusing involves guiding the conversation toward a specific topic or detail the client has already brought up. Since the nurse is initiating a broad and open-ended question, focusing is not the technique being used here.
D. Giving broad openings: This technique encourages the client to take the lead in the conversation by expressing themselves freely. Asking this question invites open communication and helps build rapport, which is characteristic of broad opening statements.
Correct Answer is A
Explanation
Rationale:
A. Severe immunodeficiency: The MMR vaccine is a live attenuated vaccine and is contraindicated in clients with severe immunodeficiency, such as those undergoing chemotherapy or with advanced HIV/AIDS. These individuals cannot mount an appropriate immune response, placing them at risk for vaccine-related complications.
B. Asymptomatic HIV: Clients with asymptomatic HIV and adequate CD4 counts may safely receive the MMR vaccine. It is not contraindicated unless the client is significantly immunocompromised.
C. Mild febrile illness: Mild illnesses, such as low-grade fever or upper respiratory infections, do not contraindicate vaccine administration. The MMR vaccine can still be safely given, as minor illness does not significantly alter vaccine response or increase risks.
D. Egg allergy: Although the MMR vaccine is cultured in chick embryo fibroblasts, it does not contain significant egg protein, and studies have shown it can be safely administered to individuals with egg allergies. An egg allergy is not a valid reason to withhold the vaccine.
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