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. "Keep objects away from your center of gravity while lifting.": Lifting objects away from the body increases strain on the back and risks injury. Objects should be kept close to the body to reduce musculoskeletal stress.

B. "Keep your feet together to provide a tight base of support.": A narrow stance decreases stability and increases the risk of losing balance. Proper lifting requires a wide, stable base with feet shoulder-width apart.

C. "Tighten abdominal muscles to improve balance.": Engaging the core stabilizes the spine, maintains proper posture, and helps prevent back injuries during lifting. This is an important ergonomic technique.

D. "Bend at the waist when lifting objects from the floor.": Bending at the waist places excessive strain on the lower back. Proper lifting technique involves bending at the knees and hips while keeping the back straight.

A. Refute the client's delusions using logic. B. Give the client one simple direction at a time. C. Allow the client to choose among a variety of activities each day. D. Establish eye contact when communicating with the client. E. Reinforce orientation to time, place, and person.

Correct Answer is ["B","D","E"]

Explanation

A. Refute the client's delusions using logic: Confronting or trying to correct delusions can increase agitation and confusion in clients with dementia. This approach is not therapeutic and should be avoided.

B. Give the client one simple direction at a time: Providing clear, single-step instructions reduces confusion and helps the client successfully complete tasks, supporting independence and minimizing frustration.

C. Allow the client to choose among a variety of activities each day: Offering too many choices can overwhelm a client with dementia, leading to anxiety and agitation. It is more effective to offer a simple choice between two options or to provide a structured routine to reduce decision fatigue.

D. Establish eye contact when communicating with the client: Eye contact enhances attention, conveys respect, and improves comprehension during interactions, which is particularly important for clients with cognitive impairment.

E. Reinforce orientation to time, place, and person: Gentle reminders and reorientation cues help maintain cognitive function, reduce anxiety, and support the client’s awareness of their environment.

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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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