A nurse assesses a newborn's lab values and notes a WBC of 28,000 mm³. What action by the nurse is best?

Document the findings in the infant's chart.

Follow unit protocol to initiate a sepsis workup.

Take a set of vital signs and notify the provider.

Perform a heel stick for a bedside blood glucose reading.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While documenting findings is a crucial nursing responsibility, a white blood cell count of 28,000 mm³ in a newborn is significantly elevated. The normal range for a newborn's WBC count is typically between 9,000 to 30,000 mm³, but a value at the higher end or exceeding this range warrants further investigation to rule out infection or other underlying conditions. Simply documenting without further action could delay necessary interventions.

Choice B rationale

A WBC count of 28,000 mm³ in a newborn raises suspicion for neonatal sepsis, a serious bloodstream infection. Unit protocols for a sepsis workup typically involve obtaining blood cultures, a complete blood count with differential, and potentially a lumbar puncture and chest X-ray to identify the source and extent of infection. Prompt initiation of these measures is critical for timely diagnosis and treatment, improving the newborn's prognosis.

Choice C rationale

Taking vital signs is a standard nursing assessment, but in the presence of an abnormal lab value suggestive of a serious condition like sepsis, it is insufficient as the sole action. While changes in vital signs can indicate infection, they may not be present in the early stages. Notifying the provider is necessary, but initiating a sepsis workup concurrently based on unit protocol allows for quicker diagnostic evaluation.

Choice D rationale

A heel stick for a bedside blood glucose reading is indicated for assessing hypoglycemia, a common concern in newborns, particularly those at risk. However, it does not directly address the significantly elevated WBC count. While infection can sometimes affect blood glucose levels, this test would not provide information about the potential underlying cause of the leukocytosis.

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Correct Answer is B

Explanation

Choice A rationale

Thoroughly cooking meat to an internal temperature of 160°F (71°C) kills the Toxoplasma gondii parasite, thus preventing transmission through ingestion of contaminated meat. This is a crucial preventive measure recommended for pregnant women.

Choice B rationale

Drinking unpasteurized milk poses a risk of toxoplasmosis, as well as other foodborne illnesses like listeriosis and brucellosis. Pasteurization is a process that heats milk to a specific temperature for a set time, killing harmful bacteria and parasites, including Toxoplasma gondii. Therefore, this statement indicates a need for further instruction, as pregnant women should consume only pasteurized dairy products.

Choice C rationale

Cat feces can contain oocysts of Toxoplasma gondii, which can become infectious after a period of sporulation. Avoiding contact with materials possibly contaminated with cat feces, such as litter boxes and garden soil, is an important measure to prevent toxoplasmosis.

Choice D rationale

Handling raw meat can expose a person to Toxoplasma gondii cysts. Avoiding touching mucous membranes of the mouth or eyes after handling raw meat and washing hands thoroughly reduces the risk of self-inoculation with the parasite.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

The nurse should anticipate a provider prescription for pyridoxine due to the client’s severe dehydration.

Rationale for correct answers

Pyridoxine (vitamin B6) is recommended for nausea and vomiting in pregnancy (NVP), commonly known as hyperemesis gravidarum (HG), especially in patients with persistent symptoms leading to dehydration. Severe dehydration is confirmed by elevated urine specific gravity (normal: 1.002–1.030), low sodium (normal: 135–145 mEq/L), and positive ketones, indicating excessive vomiting and malnutrition.

Rationale for incorrect Response 1 options

Antibiotics: There is no evidence of infection; urinalysis and WBC count are within normal limits.
Magnesium sulfate: Used for eclampsia or preterm labor prevention, not for HG.
Oxytocin: Stimulates uterine contractions and is contraindicated during early pregnancy unless labor induction is required.

Rationale for incorrect Response 2 options

Urinary tract infection: No leukocytes or nitrites in urine, and WBC count is normal (4,500–11,000/mm³).
Preeclampsia: No proteinuria or hypertension (≥140/90 mm Hg).
Preterm labor: No uterine contractions or cervical changes.

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A nurse assesses a newborn's lab values and notes a WBC of 28,000 mm³. What action by the nurse is best?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A prenatal nurse is providing instructions to a group of pregnant clients regarding measures to prevent toxoplasmosis.Which statement, if made by one of the clients, indicates a need for further instructions?

Correct Answer is B

Explanation

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

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