The parents of a newborn who is being treated for bacterial septicemia ask the nurse why their baby didn't seem very ill. The best response of the nurse is:
Select one:
"You would have seen more symptoms if you had been looking more closely at your baby."
"A newborn's immune system isn't mature, so symptoms are subtle and can be hard to recognize."
"A high fever will always be present in sick newborns, including your baby."
"A mother's immunity usually protects the infant from illness, but not in this case."
The Correct Answer is B
Choice A Reason: "You would have seen more symptoms if you had been looking more closely at your baby." This is an inappropriate response that blames the parents for missing the signs of sepsis and does not explain the Reason for the subtle symptoms.
Choice B Reason: "A newborn's immune system isn't mature, so symptoms are subtle and can be hard to recognize." This is an appropriate response that educates the parents about the immunological basis of sepsis in newborns and reassures them that they are not at fault for not noticing the symptoms.
Choice C Reason: "A high fever will always be present in sick newborns, including your baby." This is an incorrect response that contradicts the fact that newborns may not develop fever in response to infection due to their immature immune systems.
Choice D Reason: "A mother's immunity usually protects the infant from illness, but not in this case." This is an inaccurate response that implies that the mother failed to provide adequate immunity to her baby and does not address the question of why the baby did not seem very ill.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: Latent phase of the first stage of labor. This is because this phase is characterized by mild and irregular contractions, slow cervical dilation (up to 4 cm), minimal cervical effacement (up to 40%), and minimal discomfort or pain. The latent phase is also known as the early phase or preparatory phase of labor.
Choice B Reason: Transition phase of the first stage of labor. This is an incorrect answer that describes a different phase with different characteristics. The transition phase is marked by strong and frequent contractions, rapid cervical dilation (from 8 to 10 cm), complete cervical effacement (100%), and intense discomfort or pain. The transition phase is also known as the terminal phase or acceleration phase of labor.
Choice C Reason: Perineal phase of the second stage of labor. This is an incorrect answer that refers to another stage and phase with different features. The second stage of labor begins with complete cervical dilation (10 cm) and ends with delivery of the baby. The perineal phase is the last part of the second stage, where the baby's head crowns and emerges through the vaginal opening.
Choice D Reason: Active phase of the first stage of labor. This is an incorrect answer that indicates another phase with different atributes. The active phase is characterized by moderate and regular contractions, progressive cervical dilation (from 4 to 8 cm), increased cervical effacement (from 40% to 80%), and increased discomfort or pain. The active phase is also known as the middle phase or dilatation phase of labor.
Correct Answer is C
Explanation
Choice A Reason: Obtain a bilirubin level. This is an incorrect answer that indicates an irrelevant and unnecessary nursing action for a newborn with tremors or jiteriness. Obtaining a bilirubin level is a nursing action that is indicated for a newborn with jaundice (yellowish discoloration of the skin and mucous membranes), which can occur due to increased bilirubin production or decreased bilirubin excretion. Jaundice does not cause tremors or jiteriness in newborns.
Choice B Reason: Place a pulse oximeter on the newborn. This is an incorrect answer that suggests an inappropriate and insufficient nursing action for a newborn with tremors or jiteriness. Placing a pulse oximeter on the newborn is a nursing action that measures oxygen saturation and heart rate, which can indicate hypoxia (low oxygen level) or distress in newborns. Hypoxia can cause tremors or jiteriness in newborns, but it is not the only or most likely cause. Placing a pulse oximeter on the newborn does not provide enough information to diagnose or treat hypoglycemia.
Choice C Reason: Obtain a blood glucose level. This is because tremors or jiteriness are common signs of hypoglycemia (low blood glucose) in newborns, which can occur due to various factors such as prematurity, maternal diabetes, infection, or cold stress. Hypoglycemia can cause neurological damage or death if not treated promptly and effectively. Obtaining a blood glucose level is a nursing action that has the highest priority for a newborn with tremors or jiteriness, as it can confirm the diagnosis and guide the treatment.
Choice D Reason: Take the newborn's vital signs. This is an incorrect answer that implies an inadequate and delayed nursing action for a newborn with tremors or jiteriness. Taking the newborn's vital signs is a nursing action that monitors temperature, pulse, respiration, and blood pressure, which can indicate general health status and stability in newborns. Taking the newborn's vital signs may reveal signs of hypoglycemia, such as hypothermia, tachycardia, tachypnea, or hypotension, but it is not a specific or definitive test for hypoglycemia. Taking the newborn's vital signs may also waste valuable time that could be used to obtain a blood glucose level and initiate treatment.
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