The mother of a 2-day-old infant girl expresses concern about a "flea bite" type rash on her daughter's body. The nurse identifies a pink papular rash with vesicles superimposed over the thorax, back, buttocks, and abdomen. Which explanation should the nurse offer?
The rash is due to distended oil glands that will resolve in a few weeks.
This rash is characteristic of a medication reaction.
The healthcare provider is being notified about the rash.
This is a common newborn rash that will resolve after several days.
The Correct Answer is D
The rash described, pink papular rash with vesicles, is consistent with erythema toxicum neonatorum, which is a common skin condition that affects up to 50% of newborns. It typically appears within the first few days of life and resolves without treatment within 5-7 days. The rash is benign and does not require any specific treatment or intervention.
The rash is not due to distended oil glands or a medication reaction, and there is no indication in the scenario that the healthcare provider needs to be notified about the rash. Erythema toxicum neonatorum is a self-limited condition that resolves on its own, so reassurance and education for the parents are appropriate interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Incorrect- Dullness bilaterally on percussion is not a normal finding, but it is not an immediate concern after thoracentesis. It may indicate fluid accumulation or consolidation in both lungs, which could be related to other conditions such as pneumonia or heart failure.
B) Incorrect- Serosanguinous drainage from the chest tube is expected after thoracentesis, as long as it is not excessive or continuous. The nurse should monitor the amount and color of the drainage and document it accordingly.
C) Incorrect- Diminished breath sounds in the left lower lobe are also expected after thoracentesis, as the procedure removes fluid and air from the pleural space and reduces lung expansion. The nurse should auscultate the lungs before and after the procedure and compare the findings. The breath sounds should improve gradually as the lung re-expands.
D) Correct- This is a sign of tension pneumothorax, which is a life-threatening complication of thoracentesis. Tension pneumothorax occurs when air accumulates in the pleural space and creates positive pressure that pushes the mediastinum (the heart, great vessels, and trachea) to the opposite side of the chest. This can impair venous return, cardiac output, and respiratory function. The nurse should report this finding to the healthcare provider immediately and prepare to assist with needle decompression or chest tube insertion.
Correct Answer is D
Explanation
NPO status is crucial before a surgical procedure, especially when anesthesia will be administered. It helps prevent complications related to aspiration of gastric contents during the procedure. Failure to adhere to the NPO status can lead to serious respiratory problems, such as aspiration pneumonia.
It is important for the nurse to confirm the NPO status with the client to ensure that they have followed the appropriate fasting guidelines. This should be done to ensure the client's safety during the surgery.
While determining when the client last had pain medication, offering assistance to the restroom, and reviewing postoperative instructions are important aspects of preoperative care, confirming NPO status is the most critical nursing action in this particular scenario.
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