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?

A. Inability to read: Difficulty reading is not a hallmark symptom of delirium. It may be associated with visual impairment, literacy issues, or chronic cognitive decline such as dementia, but delirium is primarily characterized by acute mental status changes, not isolated reading difficulties.

B. Echopraxia: Echopraxia, the involuntary imitation of another person’s movements, is typically associated with schizophrenia or other severe psychiatric disorders. It is not a defining feature of delirium, which primarily affects attention, awareness, and cognition rather than imitation behaviors.

C. Acute onset of confusion: Delirium is distinguished by a sudden, acute onset of confusion and fluctuating levels of consciousness. Clients may exhibit disorganized thinking, poor attention, and impaired awareness, which are hallmark features that help differentiate delirium from chronic conditions like dementia.

D. Aphasia: Aphasia, or loss of the ability to understand or express speech, is more commonly related to neurological injuries such as stroke. While speech may be disorganized during delirium, the specific loss of language function like aphasia is not a primary or expected feature of this acute condition.

A. Limit periods of sitting in a chair to 4 hr: Clients with urinary incontinence should avoid prolonged sitting because it increases pressure on the skin and raises the risk of skin breakdown. Sitting should be limited to shorter periods with frequent repositioning to protect skin integrity.

B. Avoid the use of draw sheets for repositioning: Draw sheets are helpful for repositioning clients safely and reducing friction and shear forces on the skin. Avoiding their use would increase the risk of skin injury, especially in clients with incontinence who are already vulnerable.

C. Use a no-rinse perineal cleanser after incontinence: Using a no-rinse perineal cleanser helps maintain skin hygiene, removes urine and feces gently, and prevents irritation or breakdown. It is an important part of incontinence care to protect the client's skin health.

D. Keep the head of the client's bed elevated to 45º: Elevating the head of the bed to 45º degrees is helpful for respiratory support but does not directly address urinary incontinence. Bed positioning should be adjusted based on overall client needs, not specifically to manage incontinence.