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.
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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
Rationale:
A. Asks the client what her plans are for follow-up care: This is an appropriate action that demonstrates concern for the client’s continuity of care and safety, even if she decides to leave against medical advice.
B. Asks the client to sign a form releasing the hospital from legal responsibility: This is standard practice when a client leaves against medical advice, as it documents that the client was informed of potential risks and chose to leave voluntarily.This action is appropriate and does not require the charge nurse to intervene.
C. Shows the client her abnormal laboratory results: Providing relevant medical information is appropriate to help the client make an informed decision about her care before leaving the facility.
D. Asks security to detain the client until the provider is notified: Clients have the legal right to leave a healthcare facility unless they are under specific legal or mental health holds. Detaining a competent adult against their will is unlawful and violates patient rights hence requiring intervention by the charge nurse.
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