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 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.

A. Adequate hydration B. Increased iron intake C. Calorie restriction D. A low-protein diet

Correct Answer is A

Explanation

Rationale:

A. Adequate hydration: Maintaining proper fluid intake helps reduce blood viscosity and prevents sickling of red blood cells. Dehydration is a common trigger for sickle cell crises, so emphasizing hydration is crucial for prevention.

B. Increased iron intake: Most clients with sickle cell anemia do not require additional iron unless they have documented iron deficiency. Excess iron can accumulate and cause complications, especially in those receiving frequent transfusions.

C. Calorie restriction: Restricting calories is not recommended, as children with sickle cell anemia often have increased metabolic needs due to chronic hemolysis and may require adequate nutrition for growth and energy.

D. A low-protein diet: Protein is important for growth, tissue repair, and overall health. A low-protein diet is not indicated and could worsen nutritional status in children with sickle cell disease.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

A nurse is teaching the parents of a 6-year-old child who has sickle cell anemia about managing the disease. The nurse should emphasize the importance of which of the following factors to prevent a sickle cell crisis?

Correct Answer is A

Explanation

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