Question 1

The nurse knows that a symptom of right-sided heart failure is?

Accepted Answer

Answer reason: Right-sided heart failure causes systemic venous congestion because the right ventricle cannot effectively pump blood forward into the pulmonary circulation. This venous backup leads to fluid and blood pooling in dependent tissues and abdominal organs, producing hepatomegaly (often with ascites, JVD, and peripheral edema). In contrast, pulmonary edema, orthopnea, and rales are classic findings of left-sided failure due to pulmonary venous congestion. Therefore the finding that best indicates right-sided failure is enlargement/congestion of the liver.

Question 2

Jugular vein distension (JVD) is most prominent in?

Accepted Answer

Answer reason: JVD reflects elevated right atrial/central venous pressure from impaired forward flow or volume overload. In heart failure—especially right-sided failure or biventricular failure—systemic venous congestion leads to visibly distended neck veins when the patient is positioned appropriately. An MI can cause JVD mainly when it results in right ventricular infarction or acute pump failure, but this is not as consistently prominent as in heart failure. Pneumothorax only produces marked JVD in tension physiology due to obstructive shock, and an AAA does not typically raise central venous pressure.

Question 3

A nurse is assessing a client and notes an increase in the tactile fremitus. Which condition would the nurse suspect with this client?

Accepted Answer

Answer reason: Lobar consolidation from infection produces this increased vibration transmission on palpation. In contrast, conditions that increase air or separate the lung from the chest wall (e.g., emphysema or pneumothorax) typically decrease fremitus. Atelectasis more often leads to decreased fremitus unless there is associated consolidation.

Question 4

Which assessment finding most likely indicates a urinary tract infection (UTI) in a 5-year-old child?

Accepted Answer

Answer reason: UTIs in children often present with urinary frequency, urgency, dysuria, and sometimes enuresis rather than obvious systemic signs. Concentrated urine more strongly suggests dehydration and can occur from limited intake or fever, but it is not specific for infection. A subnormal temperature and lack of thirst do not fit typical pediatric UTI assessment patterns and are poor indicators compared with new incontinence.

Question 5

The nurse reviews a client's history and determines that which factor indicates a risk for candidiasis?

Accepted Answer

Answer reason: Corticosteroids reduce inflammatory and cellular immune responses, which predisposes patients to mucocutaneous fungal infections such as vulvovaginal or oral candidiasis. Menopause is more commonly associated with atrophic vaginitis due to low estrogen rather than yeast overgrowth. Nulliparity and spermicidal jelly are not classic, high-yield risk factors compared with immunosuppression.

Question 6

A client presents with a possible urinary tract infection. Which urine characteristic should the nurse assess first?

Accepted Answer

Answer reason: This can be assessed at the bedside right away and helps determine urgency for further evaluation (e.g., dipstick, culture) and symptom correlation. Specific gravity primarily reflects hydration status and concentrating ability rather than infection. Protein and acetone point more toward renal pathology or ketosis/metabolic issues and are not the earliest characteristic to assess when UTI is suspected.

Question 7

A client received burns to his entire back and left arm. The nurse uses the Rule of Nines to calculate that he has sustained burns to what percentage of his body?

Accepted Answer

Answer reason: The entire posterior trunk (the back) is 18% total body surface area. One entire arm accounts for 9%. Adding these (18% + 9%) yields 27%, which is the best match among the choices; options like 18% would omit the arm and 36% would overcount by adding the anterior trunk as well.

Question 8

The nurse is preparing to assess a client for jugular vein distention. How should the nurse position the head of the client’s bed?

Accepted Answer

Answer reason: Elevating the head of bed about 30–45° (commonly tested as 30°) optimizes visualization without collapsing the neck veins or making them overly prominent from lying flat. High Fowler’s can reduce venous filling and obscure the venous waveform, leading to underestimation. Supine positioning can exaggerate venous fullness and make it harder to identify the top of the venous column accurately.

Question 9

Which assessment is most relevant with the diagnosis of hemorrhoids?

Accepted Answer

Answer reason: A digital rectal exam helps identify internal hemorrhoids, tenderness, masses, and the presence of blood, and it supports triage for alternative causes of rectal bleeding. History elements like diet can suggest constipation risk but do not confirm the condition on assessment. Abdominal and sexual histories are less specific to evaluating anorectal venous swelling and local pathology.

Question 10

A client is experiencing early symptoms of multiple sclerosis (MS). What would the nurse expect to assess?

Accepted Answer

Answer reason: Visual complaints such as blurred vision and double vision are classic early findings and may fluctuate with fatigue or heat. Paralysis suggests more advanced motor involvement rather than an early, typical presentation. Dementia is not a hallmark early feature of MS, and grief is a psychosocial response rather than a neurologic sign to assess.

Question 11

A client recalls smelling an unpleasant odor before his seizure. What would the nurse document this as?

Accepted Answer

Answer reason: Olfactory hallucinations (a sudden unpleasant smell) are classic for a sensory aura, often linked to focal seizures involving temporal lobe structures. Documenting it as an aura helps characterize the seizure type and provides a warning sign that can improve safety planning. An atonic seizure is defined by sudden loss of muscle tone, and the postictal period occurs after the seizure with confusion or fatigue rather than a pre-seizure sensory warning.

Question 12

When auscultating the chest of a client with pneumonia, the nurse should expect to hear which type of sounds over areas of consolidation?

Accepted Answer

Answer reason: This makes breath sounds over the affected area become harsher and higher pitched, resembling tracheal/bronchial sounds rather than the soft, low-pitched vesicular pattern. Vesicular sounds are expected over normal peripheral lung tissue and are diminished when alveoli are filled. Bronchovesicular sounds are typically heard in the major bronchial areas (e.g., 1st–2nd intercostal space anteriorly, between scapulae) and are not the classic finding localized over peripheral consolidation.

Question 13

The nurse is caring for an infant with pyloric stenosis. What is a priority assessment for this infant?

Accepted Answer

Answer reason: This is the key, high-yield manifestation to assess for because it directly explains the infant’s risk for dehydration and metabolic alkalosis from loss of gastric acid. Loss of appetite is less characteristic because many infants remain hungry after vomiting (“hungry vomiter”). Explosive diarrhea suggests intestinal infection rather than an obstructive upper GI process, and coffee-ground emesis points to upper GI bleeding, which is not the typical presentation.

Question 14

The nurse would be alert for signs and symptoms of internal bleeding most commonly at which site for a client with hemophilia?

Accepted Answer

Answer reason: Bleeding into joints (especially knees, ankles, and elbows) is the most frequent site of internal bleeding and can present with warmth, swelling, pain, and decreased range of motion. Early recognition is crucial because recurrent hemarthroses lead to synovitis and chronic joint destruction. Intracranial or spinal bleeding can be catastrophic but are less common than joint bleeding, and GI bleeding is not the typical most common site.

Question 15

A 7-year-old child is diagnosed with head lice. The mother asks what nits are. What is the most accurate response by the nurse?

Accepted Answer

Answer reason: The nursing priority is accurate patient/caregiver education to support proper identification and treatment. Empty egg casings may also be seen after hatching, but the term “nits” most accurately refers to the eggs themselves rather than the shells. Adult lice and nymphs are mobile forms and are not what is meant by nits.

Question 16

A child received a bite to the hand from a large dog. The nurse would expect to assess which type of injury?

Accepted Answer

Answer reason: The hand is particularly vulnerable because of small compartments, tendons, and neurovascular structures that can be injured by crushing, increasing risk for swelling, ischemia, and functional impairment. Assessment should therefore focus on pain out of proportion, swelling, decreased range of motion, capillary refill, sensation, and tendon function, not just the superficial wound appearance. A puncture-type skin opening may be present, but the more clinically important expected mechanism with large-dog bites is underlying crush damage.

Question 17

A child is brought to the physician’s office for treatment of a rash. Many petechiae are seen over his entire body. The nurse would suspect which condition?

Accepted Answer

Answer reason: When they are widespread, the priority suspicion is a bleeding disorder because it reflects capillary bleeding under the skin. Scabies classically causes intensely pruritic papules and burrows, not petechiae over the entire body. Varicella presents with pruritic vesicles in different stages of healing rather than pinpoint purpura, and vomiting is not a primary cause of diffuse petechiae in this context.

Question 18

The nurse is assessing a neonate with a suspected infection. Which finding would the nurse anticipate?

Accepted Answer

Answer reason: Hypothermia can be an early and concerning sign of neonatal sepsis and warrants prompt evaluation and escalation of care. Decreased feeding and lethargy are more typical than increased appetite or increased activity. Flushed cheeks are nonspecific and do not reliably indicate systemic infection in a newborn.

Question 19

The nurse cares for a client diagnosed with a brainstem injury. Which is the nurse’s priority assessment?

Accepted Answer

Answer reason: Brainstem injury threatens the medullary respiratory centers that control ventilation, so airway and breathing assessment takes priority over other vital signs. Early changes in rate, pattern, or rhythm can signal impending respiratory failure and the need for immediate support. Heart rate and blood pressure are important but are secondary to ensuring adequate oxygenation and ventilation in ABC order. Intake and output is a longer-term perfusion/renal monitoring parameter and is not the first priority in this setting.

Question 20

The nurse assesses for cyanosis in a dark-skinned client. Which is the best site to assess for cyanosis in this client?

Accepted Answer

Answer reason: Cyanosis is best detected in areas with minimal melanin and good capillary perfusion, where color change from reduced oxygenation is easier to see. In dark-skinned clients, mucous membranes provide a more reliable assessment site than pigmented skin. The conjunctiva is a moist, vascular mucous membrane that allows earlier visualization of bluish discoloration. Palms and soles can still have pigment and thickened skin that can obscure subtle color changes, and earlobes are less reliable than oral/ocular mucosa for detecting central cyanosis.

Question 21

A client has pinpoint, pink-to-purple, nonblanching macular lesions 1 to 3 mm in diameter. Which term best describes the lesions?

Accepted Answer

Answer reason: Pinpoint nonblanching macules indicate capillary bleeding into the skin, producing small hemorrhagic spots. Lesions sized about 1–3 mm match the classic size definition for this finding. Purpura are larger (typically >3 mm) and ecchymoses are larger still (bruise-like patches, usually >1 cm), making them less consistent with the described diameter. A hematoma is a localized, palpable collection of blood (often with swelling), not a flat macular pinpoint lesion.

Question 22

The nurse is assessing a laboring client. The client suddenly screams and states that the baby is coming. What is the priority action by the nurse?

Accepted Answer

Answer reason: The priority in a report of imminent birth is to rapidly determine if delivery is actually imminent so the nurse can initiate emergency delivery preparations and prevent complications. Checking for crowning confirms fetal presenting part at the perineum and signals that the client should not be moved and that immediate assistance and equipment are needed. Fetal heart tones are important but do not supersede confirming imminent delivery when second-stage labor is suspected. Calming and pain medication can delay essential actions and may be unsafe when birth is imminent.

Question 23

The client is complaining of moderate pain. Which assessment by the nurse indicates a physiological response to pain?

Accepted Answer

Answer reason: An increase in blood pressure is therefore a classic physiologic indicator supporting the client’s report of pain. A decreased pulse rate is generally inconsistent with sympathetic activation and would prompt consideration of other causes (e.g., medications, conduction problems, vagal response). Behavioral findings like restlessness or guarding can accompany pain, but they are not as direct a physiologic vital-sign response as elevated blood pressure.

Question 24

Which of the following would be most important for the nurse to assess in a client with anterior pituitary hypofunction?

Accepted Answer

Answer reason: Assessing menstrual history is a sensitive, system-specific indicator of anterior pituitary hormonal deficiency and helps establish severity and chronicity. It also helps differentiate pituitary-related hypogonadism from other causes of missed menses and guides follow-up evaluation for sex hormone replacement and fertility implications. In contrast, changes in urinary output are more characteristic of posterior pituitary disorders (e.g., diabetes insipidus from ADH deficiency) rather than anterior hypofunction.

Question 25

The nurse is assessing an older client’s skin turgor and finds inelasticity present. The nurse interprets this assessment as indicating?

Accepted Answer

Answer reason: Skin turgor becomes less reliable in older adults because aging reduces dermal collagen and elastin and subcutaneous fat, leading to baseline inelasticity. Therefore, decreased turgor in an older client can reflect expected physiologic skin changes rather than fluid volume deficit. Dehydration is more accurately inferred from additional findings such as dry mucous membranes, tachycardia/orthostasis, poor urine output, or concentrated urine. Overhydration would more likely present with edema, weight gain, and pulmonary findings rather than decreased skin elasticity.

Question 26

The nurse is taking the BP on multiple clients. Which reading warrants the nurse notifying the HCP because the client's MAP is abnormal?

Accepted Answer

Answer reason: This blood pressure yields a MAP around 57 mm Hg, which is below the usual minimum needed for organ perfusion and warrants prompt provider notification and assessment for shock or medication effects. The other readings calculate to MAPs in the mid-70s to low-90s, which are generally adequate for perfusion in most adults. A common pitfall is focusing only on systolic hypotension; here the very low diastolic pressure drives a dangerously low MAP.

Question 27

The nurse is caring for the client who had a stroke affecting the right hemisphere of the brain. The nurse should assess for which problem initially?

Accepted Answer

Answer reason: Initial nursing assessment should therefore focus on safety-related neurobehavioral findings that affect immediate care planning and supervision needs. Expressive aphasia is more typical of dominant (usually left) hemisphere involvement, making it less likely here. Right hemiparesis would be expected with a left hemispheric stroke, and tetraplegia suggests high cervical spinal cord or brainstem involvement rather than a unilateral cortical stroke.

Question 28

The nurse assessed the client newly diagnosed with G. Which finding should the nurse recognize as being unrelated to the diagnosis?

Accepted Answer

Answer reason: Drooping eyelids and slurred speech fit typical ocular/bulbar involvement, and leg weakness can occur as generalized weakness. Circumoral tingling is a sensory paresthesia and is more consistent with electrolyte disturbances (e.g., hypocalcemia) or hyperventilation-related alkalosis rather than a primary neuromuscular junction weakness disorder. Because MG is primarily a motor weakness condition without sensory symptoms, this finding is unrelated.

Question 29

The nurse is assessing the 3-year-old child. Which finding would alert the nurse to further explore for signs of hypopituitarism?

Accepted Answer

Answer reason: A 3-year-old who has had no growth for an entire year suggests impaired pituitary-driven growth and warrants focused endocrine evaluation and growth-curve review. Lethargy and confusion are nonspecific and more consistent with acute metabolic or neurologic problems rather than a classic presenting sign of isolated pituitary hormone deficiency. Hyperglycemia is not expected; pituitary hormone deficiencies more often predispose to hypoglycemia (e.g., from cortisol and/or GH deficiency).

Question 30

While palpating a client’s abdomen, the nurse notes a pulsating abdominal mass. This may indicate which condition?

Accepted Answer

Answer reason: An aneurysm transmits arterial pulsations to the abdominal wall, especially in thinner clients, making the mass feel expansile rather than simply “bouncing” under the fingers. Splenomegaly may be palpable in the left upper quadrant but is typically not pulsatile. Gastric distention and gastritis cause abdominal fullness or tenderness rather than a distinctly pulsating mass, and recognizing this finding is important because deep palpation can increase rupture risk in a suspected aneurysm.

Question 31

The nurse should assess a client with secondary varicose veins for which signs and symptoms?

Accepted Answer

Answer reason: This leads to dependent ankle/leg swelling and brownish hyperpigmentation (hemosiderin staining), which are typical findings with secondary varicose veins. In contrast, pallor with severe pain and absent hair growth are more consistent with arterial insufficiency rather than venous disease. Severe pain is not the hallmark of uncomplicated varicosities and should prompt evaluation for other acute problems (e.g., DVT) if present.

Question 32

Which nursing intervention should be included in the immediate postoperative management of a client who has undergone gastric resection?

Accepted Answer

Answer reason: Monitoring bowel sounds helps the nurse evaluate whether the gastrointestinal tract is resuming function and guides safe progression from NPO to oral intake, reducing aspiration and distention risks. In contrast, routine gastric pH monitoring is not a standard immediate post-resection nursing surveillance parameter for complications compared with direct assessment findings and output characteristics if a tube is present. Nutritional support is important after resection but is typically a subsequent priority once bowel function returns and the ordered feeding route is established.

Question 33

Which assessment finding would a client in the early stages of peritonitis exhibit?

Accepted Answer

Answer reason: This produces early hyperperistalsis with louder, more frequent bowel sounds before paralytic ileus develops later. As the condition progresses, bowel sounds typically become hypoactive or absent and distention becomes more prominent. Marked board-like rigidity and severe diffuse pain are classic findings but are more characteristic of established/worsening peritoneal inflammation rather than the earliest stage.

Question 34

The nurse is assessing a client with an early diagnosis of stage I Hodgkin’s disease. Which finding is the nurse likely to document?

Accepted Answer

Answer reason: In early-stage disease, these constitutional symptoms may be present even before widespread organ involvement is evident on exam. Splenomegaly can occur but is more suggestive of more extensive lymphatic/reticuloendothelial involvement and is less consistently an early, expected finding than a classic B symptom. Pericarditis and persistent hypothermia are not typical presenting features of Hodgkin’s disease.

Question 35

A client diagnosed with leukemia is now experiencing neutropenia. Which of the following is a priority assessment by the nurse?

Accepted Answer

Answer reason: g., pneumonia) in immunocompromised clients. Early lung infection may present subtly, so focused assessment for new crackles, diminished airflow, or other changes can detect deterioration before overt sepsis develops. This assessment directly targets the highest-risk complication (infection leading to hypoxia/respiratory failure) and supports prompt escalation for cultures, imaging, and antimicrobials if indicated. While blood pressure is important for shock surveillance, it often changes later; a focused respiratory assessment can identify an earlier, high-yield warning sign in neutropenia.

Question 36

Which of the following symptoms are considered signs of a fracture?

Accepted Answer

Answer reason: This option reflects typical local signs a nurse would assess when a fracture is suspected. Options featuring coolness, tingling, or loss of pulses point more toward distal neurovascular compromise/ischemia (e.g., compartment syndrome or arterial injury), which are serious complications rather than general signs of fracture. Therefore the best answer is the set of expected local injury findings.

Question 37

The nurse assesses clear fluid draining from the nose of a client who experienced head trauma 3 hours ago. The nurse suspects this finding may indicate?

Accepted Answer

Answer reason: Clear, watery nasal drainage shortly after head trauma is concerning for cerebrospinal fluid rhinorrhea from a dural tear, classically associated with a basilar skull fracture. This is a high-risk assessment finding because it signals a possible communication between the intracranial space and the nasopharynx, increasing risk for meningitis and indicating the need to avoid nasal instrumentation. A concussion typically causes transient neurologic symptoms (e.g., confusion, headache) rather than CSF leakage. Sinus infection may cause nasal discharge, but it is usually mucopurulent and not an acute post-trauma finding.

Question 38

When assessing a client with glaucoma, a nurse expects which finding?

Accepted Answer

Answer reason: This finding aligns with glaucoma’s pathophysiology of impaired aqueous humor outflow leading to increased pressure and optic/ocular changes. An intraocular pressure of 15 mm Hg is within the normal range and would not support glaucoma. A “soft” globe suggests low intraocular pressure (hypotony), not the increased pressure expected with glaucoma.

Question 39

A nurse observes a client experiencing involuntary, jerking, rhythmic movements of the eyes. The nurse documents this which condition?

Accepted Answer

Answer reason: Diplopia refers to double vision, a subjective visual complaint rather than an observed rhythmic movement. Exophthalmos is forward protrusion of the eyeballs (often thyroid-related) and does not describe jerking movements. Oculogyric crisis is a dystonic reaction with sustained upward/lateral deviation of the eyes, typically not rhythmic jerking.

Question 40

Which sign or symptom of increased intracranial pressure (ICP) after head trauma would appear first?

Accepted Answer

Answer reason: New-onset agitation, restlessness, and confusion often precede later vital-sign changes. Bradycardia and widened pulse pressure are components of Cushing’s response, which are typically late findings associated with significant intracranial hypertension and impending herniation. Large volumes of dilute urine suggests diabetes insipidus from pituitary injury and is not the classic earliest sign of rising ICP.

Question 41

The following are found during the assessment of a 1-month-old child. Which of the following would lead the nurse to suspect a cardiac defect?

Accepted Answer

Answer reason: Poor intake at 1 month is a red flag for early heart failure (often accompanied by tachypnea, diaphoresis with feeds, and poor weight gain). In contrast, weight gain is reassuring rather than suspicious, and hyperactivity is not a typical presentation in a 1-month-old. Pink mucous membranes suggest adequate oxygenation and argue against significant cyanotic heart disease.

Question 42

The nurse is preparing to assess a child with a possible cardiac anomaly. It is most important for the nurse to assess which of the following?

Accepted Answer

Answer reason: Measuring pressures in all four extremities helps detect patterns such as higher arm pressures with diminished leg pressures suggestive of obstructive left-sided lesions (e.g., coarctation), which can be missed with a single-limb reading. This assessment directly informs urgency, need for further diagnostics, and monitoring for complications like poor systemic perfusion. By contrast, skin turgor and temperature are general assessments and do not specifically screen for hemodynamically significant congenital anomalies as effectively as extremity BP comparison.

Question 43

The parents of an infant who had cleft lip repair ask the nurse how the area will appear when it is healed. What is the best response by the nurse?

Accepted Answer

Answer reason: With appropriate surgical technique and routine scar maturation, the incision line typically becomes a fine line that is relatively inconspicuous over time. Telling parents to expect a large scar or major deformity is inaccurate and can increase anxiety, since those outcomes are not typical goals or expectations of modern repair. A distorted jaw is not an expected consequence of cleft lip repair itself and would suggest a different congenital issue or complication rather than normal healing.

Question 44

The nurse would explain to the parents of a newborn with a cleft lip and palate that they will need to schedule an appointment with which specialist?

Accepted Answer

Answer reason: Early hearing assessment and ongoing ear management are essential to support normal speech and language development. An ENT specialist evaluates hearing, monitors for effusions, and coordinates interventions such as tympanostomy tubes when indicated. While feeding support is important, it does not address the high-priority risk of hearing-related complications that require specialty assessment and follow-up.

Question 45

A neonate is suspected of having a tracheoesophageal fistula (type III/C). Which symptom would be seen on the initial assessment?

Accepted Answer

Answer reason: This leads to frothy secretions and drooling early in the newborn assessment, often with choking/coughing and respiratory distress when feeding is attempted. Polyhydramnios is an antenatal clue in the mother rather than a neonatal assessment finding. Excessive vomiting is less characteristic than inability to handle secretions, and mottling is nonspecific and not a hallmark presentation.

Question 46

A child is seen in the pediatrician’s office for complaints of bone and joint pain. Which other assessment finding may suggest leukemia?

Accepted Answer

Answer reason: Thrombocytopenia from marrow failure commonly presents with easy bruising, mucosal bleeding, and petechiae, making this a key assessment clue when paired with bone/joint pain. Bone pain occurs from marrow expansion and pressure, so concurrent bleeding manifestations strengthen suspicion for leukemia. Increased activity level and increased appetite are inconsistent with typical leukemia-related fatigue and weight/appetite loss, while abdominal pain is less specific and not as strongly linked as thrombocytopenic bleeding signs.

Question 47

A child is brought to the emergency department after an extended period of sledding with suspected frostbite of the hands. The nurse assesses the skin on the hands and documents it as?

Accepted Answer

Answer reason: Frostbite causes intense peripheral vasoconstriction and ice-crystal injury that markedly reduces perfusion to the affected tissue. This typically makes the skin appear pale/white (often with numbness and a “waxy” feel) before rewarming. Deep flushing and redness are more consistent with rewarming injury or frostnip after perfusion returns, not the classic initial assessment finding in suspected frostbite. Blistering can occur later after thawing and is not the most reliable immediate hallmark for documentation at first presentation.

Question 48

A child fell at camp and sustained a bruise to his thigh. Which description would accurately describe the bruise after 1 week?

Accepted Answer

Answer reason: Around 5–7 days, conversion to biliverdin and then bilirubin commonly produces a green to yellow appearance. Earlier stages are typically reddish-blue/purple from fresh extravasated blood, and later the discoloration fades as macrophages clear pigments. Full resolution at exactly 1 week is less reliable, especially on the thigh where bruises can persist longer.

Question 49

The nurse is assessing a child suspected of having Kawasaki syndrome. The nurse would assess the mouth for which finding?

Accepted Answer

Answer reason: Typical mouth findings include erythematous, cracked lips and a "strawberry" tongue from prominent papillae on an inflamed tongue. This finding supports the clinical criteria used to diagnose the syndrome and helps prompt evaluation for coronary artery involvement. Koplik's spots are classically associated with measles, and vesicular oral lesions are more consistent with viral stomatitis (e.g., HSV), making them less fitting for Kawasaki.

Question 50

During an examination of a 5-month-old infant, a flat, dull pink, macular lesion is noted on the infant's forehead. The nurse suspects which condition?

Accepted Answer

Answer reason: These lesions are typically blanchable and tend to fade over time, fitting the description of a subtle, flat pink mark. In contrast, strawberry hemangiomas usually become raised, bright red, and proliferate during early infancy, and cavernous hemangiomas are deeper with a bluish hue. Nevus flammeus (port-wine stain) is usually a darker red-to-purple lesion that persists and can thicken with age rather than fading.

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