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 A
Explanation
Rationale:
A. "It expresses your wishes regarding health care when you can no longer communicate.": Advance directives are legal documents that state a client's preferences for medical care if they become unable to communicate those decisions themselves. This includes choices about life-sustaining treatments, resuscitation, and organ donation.
B. "It specifies your choices regarding funeral arrangements.": Funeral arrangements are typically addressed in a will or separate personal document, not in advance directives. Advance directives focus on medical decisions, not postmortem planning.
C. "It defines the criteria for the distribution of your assets.": The distribution of assets is handled through a last will and testament or estate planning documents, not through an advance directive. The directive is solely for healthcare-related decisions.
D. "It appoints a health care provider to speak for you with power of attorney for health care.": An advance directive may include the appointment of a health care proxy or agent, but it does not appoint a health care provider. It designates a trusted individual—not a clinician to make decisions if the client is incapacitated.
Correct Answer is ["B","C","D"]
Explanation
Rationale:
A. Decreased skin turgor: Decreased skin turgor is a sign of dehydration or fluid imbalance and is not related to compartment syndrome. It does not reflect changes in perfusion or nerve compression caused by increased compartment pressure.
B. Sensation of tingling: Tingling or paresthesia is an early sign of nerve compression due to rising pressure within a muscle compartment. It indicates compromised nerve function and is a key symptom of evolving compartment syndrome.
C. Diminished capillary refill: Delayed or diminished capillary refill suggests impaired perfusion. In a newly placed cast, this can indicate increased pressure restricting blood flow—an early and critical sign of compartment syndrome.
D. Pale-colored toes: Pallor in the extremities is a sign of decreased arterial blood flow. Pale-colored toes after cast placement suggest compromised circulation, which is consistent with compartment syndrome.
E. Pain relieved by analgesia: Pain that is unrelieved by analgesia especially pain out of proportion to the injury is a hallmark of compartment syndrome. Pain that is relieved by medication does not indicate compartment syndrome and may reflect expected postoperative discomfort.
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