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 C

Explanation

A. Clostridium difficile: C. difficile infections are typically managed within healthcare facilities and are not considered reportable to local health departments under standard public health reporting requirements.

B. Herpes simplex virus: HSV infections are common and usually not reportable to public health authorities, except in cases of neonatal herpes or unusual outbreaks, as routine cases are managed clinically.

C. Chlamydia trachomatis: Chlamydia is a sexually transmitted infection that is nationally notifiable. Reporting to the local health department is required to track incidence, prevent spread, and facilitate partner notification and treatment.

D. Human papilloma virus: HPV infections are widespread and typically not reportable because most cases are asymptomatic or self-limiting. Reporting is not required for routine surveillance or treatment purposes.

A. "You will be given access to the medical records of every client in the facility." B. "You will be asked to change your password once per year." C. "Information Technology will install a firewall to secure client information." D. "Documentation of sensitive material is performed by the charge nurse."

Correct Answer is C

Explanation

A. "You will be given access to the medical records of every client in the facility.": Access to electronic medical records is restricted based on the nurse’s role and need-to-know basis to protect client confidentiality. Nurses only view records of clients under their care.

B. "You will be asked to change your password once per year.": Most facilities require more frequent password changes, often every 60–90 days, to maintain system security. Annual changes alone are insufficient for protecting client data.

C. "Information Technology will install a firewall to secure client information.": Firewalls and other cybersecurity measures help protect electronic health information from unauthorized access. Including this ensures nurses understand that the system has built-in technical safeguards for privacy and security.

D. "Documentation of sensitive material is performed by the charge nurse.": All licensed nurses are responsible for accurate, complete, and timely documentation of client care, including sensitive material. Responsibility is not limited to the charge nurse.

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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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