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 ["A","B","D","E"]
Explanation
A. Expected outcome of the procedure: The provider must explain the anticipated results of the colon resection so the client can make an informed decision about proceeding with the surgery.
B. Potential complications: The client should be informed of the risks and possible adverse events associated with the procedure, which is essential for informed consent.
C. Cost of the procedure: Financial information is not required for informed consent. While helpful for planning, it is not part of the medical disclosure required by the provider.
D. Explanation of the procedure: A clear description of the surgical steps allows the client to understand what the procedure entails, which is a fundamental component of informed consent.
E. Possible alternative treatments: The client must be aware of other treatment options, including the choice of no treatment, to make an informed decision regarding surgery.
Correct Answer is C
Explanation
Rationale:
A. "I don't think you understand the risks to your health.": This response is dismissive of the client’s autonomy and implies the nurse is questioning the client’s decision-making ability. It can create a defensive reaction rather than supporting informed consent.
B. "You should talk with your family about it first.": While family support can be helpful, the decision for surgery ultimately rests with the client. Suggesting family involvement at this point could undermine the client’s right to make an independent healthcare decision.
C. "I will notify your provider regarding this decision.": This response respects the client’s autonomy and ensures the healthcare team is promptly informed. It also facilitates further discussion between the provider and client about the decision, ensuring it is fully informed.
D. "Let me remind you of the benefits of the surgery.": While reviewing benefits can be part of informed consent, doing so after the client has expressed a clear decision not to proceed may be perceived as coercive rather than supportive.
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