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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "The nurse will initiate acupuncture when I arrive at the unit.": Acupuncture must be performed by a trained and licensed practitioner, not a bedside nurse. While it can be used for labor pain, it is not typically initiated by nursing staff upon admission.
B. "I can use my ultrasound picture as a focal point during contractions.": Focal point techniques, such as concentrating on a meaningful object like an ultrasound picture, help distract from pain and promote relaxation.
C. "A transcutaneous electrical nerve stimulator will help with pelvic pressure.": TENS units are primarily effective for back pain in early labor rather than pelvic pressure. They work by stimulating sensory nerves to reduce pain perception but are less effective for deep pelvic discomfort.
D. "My nurse can teach me biofeedback at the beginning of labor.": Biofeedback requires prior training and practice before labor begins to be effective. Learning it for the first time during active labor is impractical and unlikely to yield good results.
Correct Answer is B
Explanation
A. Playing with a jump rope: Jump rope requires advanced gross motor coordination and balance, which typically develops around age 4–5 years. A 30-month-old is not developmentally ready for this activity.
B. Playing with a large plastic truck: Toddlers around 2–3 years enjoy manipulating large toys such as trucks, cars, or blocks. This play supports fine and gross motor skills, hand-eye coordination, and imaginative exploration appropriate for their developmental stage.
C. Playing with dress-up clothes: Pretend or dress-up play becomes more common around age 3–4 years, as symbolic thinking and role-playing abilities develop. A 30-month-old may begin simple pretend play but usually engages in more concrete, manipulative play.
D. Playing with an imaginary friend: Engaging in complex imaginative play, such as interacting with an imaginary friend, usually emerges around age 3–4 years, reflecting more advanced cognitive and social development than expected at 30 months.
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