A nurse is providing care to a newborn. The nurse suspects that the newborn is developing sepsis based on which assessment finding?

temperature instability

increased urinary output

wakefulness

interest in feeding

Answer and Explanation

The Correct Answer is A

A.   Correct. Temperature instability, including fever or hypothermia, can be a sign of sepsis in newborns, as it reflects the body's response to infection.
B.   Increased urinary output is not typically associated with sepsis in newborns and may have other causes, such as adequate fluid intake or renal function.
C.   Wakefulness is a normal behavior in newborns and is not specific to sepsis.
D.   Interest in feeding is a positive sign and indicates the newborn's responsiveness to hunger cues, but it is not specific to sepsis.

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

Explanation

A. In small-for-gestational age infants, kangaroo care may increase heat loss due to evaporation, conduction, or convection from the parent's skin or clothing. The nurse should minimize kangaroo care and use other methods of warming such as radiant warmers, incubators, or swaddling.
B. Assessing the axillary temperature regularly helps monitor the infant's temperature and response to interventions.
C. Encouraging skin-to-skin contact helps promote thermal regulation and bonding between the infant and parents. Unlike kangaroo care, skin-to-skin contact does not involve covering the infant with clothing or blankets, which can reduce heat loss by radiation or convection. The nurse should encourage skin-to-skin contact when possible and monitor the infant's temperature closely.
D. Assessing the environment for sources of heat loss is important for minimizing heat loss and promoting thermal regulation.
E. Reviewing maternal history can provide insights into potential risk factors or contributing factors to the infant's condition, such as maternal age, parity, weight, height, nutrition, smoking, alcohol, drug use, chronic diseases, infections, placental abnormalities, fetal anomalies, or complications during pregnancy or delivery.
F. Bathing the neonate with warmer water may increase the risk of overheating and should be avoided in infants at risk of thermal instability.

A. A lack of fully developed hearing B. A less discriminating sense of touch C. Visual acuity that has not fully developed D. A less discriminating sense of taste

Correct Answer is D

Explanation

A. Hearing is not directly related to the risk of accidental ingestion.
B. Touch is not typically involved in the identification of substances for ingestion.
C. Visual acuity plays a role in identifying substances but may not directly influence the risk of accidental ingestion.
D. At the age of 3, children may have a less discriminating sense of taste, making them more likely to put potentially harmful substances in their mouths.

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A nurse is providing care to a newborn. The nurse suspects that the newborn is developing sepsis based on which assessment finding?

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Naxlex Comprehensive Predictor Exams

A small-for-gestational age infant is admitted to the observational care unit with the nursing diagnosis of ineffective thermoregulation related to lack of fat stores as evidenced by persistent low temperatures. Which are appropriate nursing interventions? Select all that apply.

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

Explanation

The nurse is providing teaching about accidental poisoning to the family of a 3-year-old. The nurse understands that a child of this age is at increased risk of accidental ingestion due to which sensory alteration?

Correct Answer is D

Explanation

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