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
Explanation
Rationale:
A. Ensure the client is aware of the scheduled time for the procedure: While knowing the time of surgery is helpful for preparation, it is not a requirement for informed consent. The key issue is whether the client understands the procedure itself and its implications.
B. Make sure the client has been informed about the risks of the procedure: Before witnessing informed consent, the nurse must confirm that the client has received complete information from the provider about the procedure, including its purpose, risks, benefits, and alternatives. This ensures the client is making an informed decision.
C. Ensure the client receives opioid medication prior to giving consent for the procedure: Administering opioids before consent can impair the client's cognitive ability to understand and voluntarily agree. Consent must be obtained while the client is alert and oriented, prior to any sedating medications.
D. Make sure the client's family agrees to the procedure: Consent is only valid when given by the competent client. Family agreement is not legally required unless the client is unable to consent and a legal surrogate is designated.
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