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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Offer the client fluids and toileting every 15 min: While regular offering of fluids and toileting is essential, the standard protocol is typically every 2 hours not every 15 minutes unless otherwise indicated. Overly frequent checks may not be feasible or necessary unless clinically justified.
B. Obtain a prescription before removing the restraints: Mechanical restraints are considered a restrictive intervention and require a physician's order for both application and removal. This ensures medical oversight and client safety.
C. Ensure the restraints are removed from the client within 6 hr: Time limits for restraints depend on the client’s age. For adults, a new order must be obtained every 4 hours, not 6. For children and adolescents (9-17 years), it's 2 hours, and for children under 9 years, it's 1 hour.
D. Place the client in prone position on a soft mattress: Prone restraint positions are not safe and are strongly discouraged due to risk of asphyxiation or injury. Restraints should always allow for safe positioning, typically with the client in a supine or semi-Fowler’s position.
Correct Answer is A
Explanation
Rationale:
A. "My advance directives will list what treatments I want if I'm unable to communicate.": Advance directives allow individuals to specify their healthcare preferences in situations where they are incapacitated. This includes decisions about life-sustaining treatments, resuscitation, and other medical interventions.
B. "My advance directives must be signed by my adult child in the presence of a judge.": Advance directives usually require the client’s signature and the signatures of two adult witnesses or notarization, depending on state laws. A judge’s involvement is typically not required.
C. "My family will be informed about my funeral choices in my advance directives.": Funeral or postmortem arrangements are not addressed in advance directives. These documents strictly relate to medical care preferences and decision-making in the event the client becomes unable to speak for themselves.
D. “I can indicate the organs will donate in my advance directives.": While some advance directive forms may include a section about organ donation, formal organ donor registration is typically completed through a driver’s license, organ donor card, or state registry—not as the main purpose of an advance directive.
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