A nurse is conducting an admission assessment on a newborn. Which of the following findings should the nurse identify as an indication of sepsis?

Acrocyanosis

Hypertension

Rust-stained urine

Retractions

Answer and Explanation

The Correct Answer is D

Rationale:

A. Acrocyanosis: This is a bluish discoloration of the hands and feet that is common in newborns during the first 24 to 48 hours after birth due to immature circulation. It is not a sign of sepsis.

B. Hypertension: Newborns with sepsis are more likely to present with hypotension due to systemic infection and poor perfusion. Hypertension is not typically associated with neonatal sepsis.

C. Rust-stained urine: This discoloration can occur in newborns from urate crystals in the first few days of life and is considered a normal finding, not an indicator of infection.

D. Retractions: Retractions indicate increased work of breathing and respiratory distress, which can occur in newborn sepsis due to systemic infection affecting respiratory function. This is a concerning finding that warrants prompt evaluation.

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Correct Answer is B

Explanation

Rationale:

A. Perform an ECG every 12 hr: Frequent ECGs are typically done during the acute phase to monitor for arrhythmias, but by day 3 post-MI, continuous or as-needed monitoring is more appropriate unless new symptoms occur.

B. Obtain a cardiac rehabilitation consultation: Early involvement of cardiac rehab supports gradual activity progression, lifestyle modification, and psychosocial support, improving long-term outcomes after MI.

C. Draw a troponin level every 4 hr: Troponin testing is most useful for diagnosing and trending damage during the first 24 hours; by day 3, levels have usually peaked and are declining.

D. Place the client in a supine position while resting: Supine positioning can increase cardiac workload; a semi-Fowler's position is preferred to reduce venous return and ease breathing.

A. Verbally remind the staff member of the expected behaviour changes. B. Suspend the staff member from work for several days. C. Give the staff member a written warning about the behavior. D. Dismiss the staff member from employment at the facility. E. Set up a meeting to speak with the staff member about the behavior.

Correct Answer is E,A,C,B,D

Explanation

Rationale:

A. Verbally remind the staff member of the expected behaviour changes: After the initial meeting, a verbal reminder reinforces expectations and gives the staff member an opportunity to improve without formal penalties.

B. Suspend the staff member from work for several days: Suspension is used when prior interventions have not resulted in improvement. It serves as a serious consequence, giving time for reflection before returning to work.

C. Give the staff member a written warning about the behavior: A written warning follows a verbal reminder if the unprofessional behavior continues. It creates a formal record and communicates the seriousness of the issue.

D. Dismiss the staff member from employment at the facility: Termination is the final step when all other corrective measures have failed and the behavior persists, ensuring workplace standards and safety are maintained.

E. Set up a meeting to speak with the staff member about the behavior: The first action is to meet privately to discuss the observed behavior, clarify expectations, and begin the progressive discipline process in a constructive manner.

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A nurse is conducting an admission assessment on a newborn. Which of the following findings should the nurse identify as an indication of sepsis?

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Correct Answer is B

Explanation

Correct Answer is E,A,C,B,D

Explanation

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