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?

Answer and Explanation

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.

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Correct Answer is A

Explanation

A: Image A shows hands with fingers that appear elongated and have widened nail beds. The fingertips look rounded and bulbous, which is characteristic of clubbing. Clubbing often results from chronic hypoxia and is seen in conditions like congenital heart disease, cystic fibrosis, and chronic lung disease.

B: Image B shows normal-appearing fingers with straight nail beds and no signs of bulbous enlargement at the fingertips. This appearance is not consistent with clubbing and represents normal finger structure without signs of chronic hypoxia or circulatory issues.

A. Active movement is present B. Pain is 4 on scale of 0 to 10 C. Capillary refit is less than 2 seconds D. Skin is cool to the touch

Correct Answer is D

Explanation

A. Active movement is present: The presence of active movement in the fingers and toes of the affected arm indicates that nerve and muscle function are intact, which is a positive finding. It indicates there is no impairment in function of the affected arm.

B. Pain is 4 on scale of 0 to 10: A pain level of 4 is moderate pain and might be expected after a fracture. As long as pain is being managed appropriately with prescribed medications and no other concerning symptoms are present, it does not necessarily require immediate reporting.

C. Capillary refill is less than 2 seconds: A capillary refill time of less than 2 seconds is normal. This suggests good blood flow to the affected arm and is not an issue that needs reporting.

D. Skin is cool to the touch: A cool skin temperature on the affected arm could indicate impaired circulation, possibly due to swelling or tightness of the cast, which could lead to compartment syndrome—a serious condition that requires immediate intervention. Therefore, this finding should be reported to the provider immediately.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a group of clients. Which of the following images indicates a client the nurse should identify as exhibiting clubbing of the fingers?

Correct Answer is A

Explanation

A nurse is caring for a client who has a fractured arm in a cast. Which of the following findings about the affected arm should the nurse report to the provider?

Correct Answer is D

Explanation

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