A nurse is collecting data from a newborn who was born 24 hrs ago. Which of the following images should the nurse identify as an indication that the newborn has erythema toxicum?
<p><img src="https://naxlex.com/nursing/assets/images/study_guides/Picture1A_1746709004.jpg" class="img-fluid" /></p>
<p><img src="https://naxlex.com/nursing/assets/images/study_guides/Picture1AB_1746709047.jpg" class="img-fluid" /></p>
The Correct Answer is B
A: Image A shows a newborn wrapped in a blanket with generalized redness on the face but without distinct blotchy areas or pustules. This appearance is more consistent with normal transitional skin changes such as acrocyanosis or overall mild skin redness after birth. It does not match the appearance of erythema toxicum.
B: Image B shows a close-up of the newborn’s face with visible small red blotchy spots, especially around the cheeks and nose. This matches the classic presentation of erythema toxicum, a benign newborn rash appearing within the first 24 hours. It is characterized by red patches with possible small pustules scattered over the face and body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "I should limit my intake of leafy green vegetables.": Limiting leafy green vegetables is associated with warfarin therapy because of their vitamin K content. It is not relevant to metoprolol, which primarily affects the cardiovascular system and does not interact significantly with dietary vitamin K.
B. "I may experience loss of taste.": Loss of taste is not a common side effect of metoprolol. Metoprolol is more associated with cardiovascular side effects such as bradycardia, hypotension, and dizziness rather than alterations in taste perception.
C. "I need to be careful when standing up from bed.": This is correct because metoprolol can cause orthostatic hypotension, leading to dizziness or lightheadedness upon standing. Clients are advised to rise slowly from a lying or seated position to reduce the risk of falls and fainting.
D. "I should expect some weight loss.": Metoprolol is more commonly associated with weight gain or no significant weight change rather than weight loss. Clients taking beta-blockers sometimes experience fluid retention or a slowed metabolism, leading to modest weight gain.
Correct Answer is A
Explanation
A. "I will support your decision and help you explain it to others.": This response respects the client's autonomy and decision-making rights. It also offers emotional support and assistance in communicating the client's wishes to other healthcare team members or family, promoting dignity and advocacy.
B. "Let me explain the pros and cons of your decision.": This response may sound judgmental and suggest that the nurse is trying to influence the client's decision. Once a competent client has made a choice, the nurse’s role is to support it rather than attempt to persuade or second-guess it.
C. "I suggest you discuss this decision with your family first.": While family discussions can be valuable, the client has the primary right to make healthcare decisions. Suggesting they must discuss it with family could delay honoring the client’s wishes or create unnecessary emotional pressure.
D. "I will send the social worker in to discuss this decision with you.": While a social worker can provide additional support, immediately deferring to someone else instead of acknowledging the client’s decision can make the client feel dismissed. The nurse should first validate and support the client’s expressed wishes.
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