Which of the following would the nurse expect to find in a newborn who is developing sepsis? Select one:
Hyperglycemia and increased appetite.
Increased urinary output and spitting up mucous.
Wakefulness and ruddy appearance.
Temperature instability and lethargy.
The Correct Answer is D
Choice A Reason: Hyperglycemia and increased appetite. This is an incorrect answer that describes symptoms of diabetes mellitus, not sepsis. Diabetes mellitus is a chronic metabolic disorder where the body cannot produce or use insulin effectively, which results in high blood glucose levels and impaired glucose tolerance. Diabetes mellitus can affect newborns if the mother has pre-existing or gestational diabetes, which can cause macrosomia, hypoglycemia, or congenital anomalies.
Choice B Reason: Increased urinary output and spitting up mucous. This is an incorrect answer that indicates normal or benign conditions, not sepsis. Increased urinary output is a normal finding in newborns, as they eliminate the excess fluid that was accumulated during pregnancy. Spitting up mucous is a common occurrence in newborns, as they clear their airways of amniotic fluid or secretions.
Choice C Reason: Wakefulness and ruddy appearance. This is an incorrect answer that suggests healthy or normal characteristics, not sepsis. Wakefulness is a sign of alertness and responsiveness in newborns, which reflects their neurological development and adaptation. Ruddy appearance is a reddish color of the skin that is normal in newborns, especially in term or post-term infants, which indicates adequate oxygenation and hemoglobin levels.
Choice D Reason: Temperature instability and lethargy. This is because temperature instability and lethargy are common signs of sepsis in newborns, which indicate systemic infection and inflammation. Sepsis is a life-threatening condition where the body's response to infection causes tissue damage, organ failure, or death. Sepsis can occur in newborns due to maternal, fetal, or neonatal factors, such as chorioamnionitis, premature rupture of membranes, prolonged labor, invasive procedures, or bacterial colonization.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: Macrosomic newborn. This is a correct answer that describes a possible complication of post-term pregnancy. A macrosomic newborn is a newborn that weighs more than 4000 grams or 8 pounds 13 ounces at birth. It can occur in post-term pregnancies due to prolonged exposure to maternal glucose and insulin. It can increase the risk of birth injuries, shoulder dystocia, cesarean delivery, and hypoglycemia.
Choice B Reason: Intrauterine growth restriction (IUGR). This is a correct answer that indicates a potential problem of post-term pregnancy. IUGR is a condition where the fetal growth is slower than expected for gestational age. It can occur in post-term pregnancies due to placental insufficiency, aging, or calcification, which can impair nutrient and oxygen delivery to the fetus. It can increase the risk of fetal distress, hypoxia, acidosis, and stillbirth.
Choice C Reason: Umbilical cord prolapse. This is an incorrect answer that does not reflect a risk of post-term pregnancy, but rather a risk of other factors such as prematurity, low birth weight, breech presentation, multiple gestation, polyhydramnios, or artificial rupture of membranes.
Choice D Reason: Meconium Aspiration Syndrome (MAS). This is a correct answer that denotes a possible complication of post-term pregnancy. MAS occurs when fetal stool (meconium) enters into the lungs before or during birth, causing airway obstruction, inflammation, and infection. MAS usually affects term or post-term infants who experience fetal distress or hypoxia in utero. It can cause respiratory distress syndrome (RDS), persistent pulmonary hypertension (PPHN), or chronic lung disease (CLD).
Correct Answer is B
Explanation
Choice A Reason: Prepare for IV dextrose administration. This is an incorrect answer that indicates an unnecessary and invasive intervention for an IDM with normal blood glucose. IV dextrose administration is indicated for an IDM with severe or persistent hypoglycemia, which is defined as a blood glucose below 40 mg/dL or below 60 mg/dL after two feedings.
Choice B Reason: Provide routine care, per hospital IDM protocol. This is because a blood glucose of 60 is within the normal range for an IDM, which is 40 to 80 mg/dL. An IDM is a newborn whose mother has pre-existing or gestational diabetes, which can affect the fetal and neonatal glucose metabolism and regulation. An IDM may have hypoglycemia (low blood glucose), hyperglycemia (high blood glucose), or other complications such as macrosomia, polycythemia, or congenital anomalies. An IDM requires routine care and monitoring according to the hospital IDM protocol, which may include blood glucose testing, feeding, temperature regulation, and observation for signs of distress.
Choice C Reason: Place the infant in a warmed incubator. This is an incorrect answer that suggests an irrelevant and potentially harmful action for an IDM with normal blood glucose. Placing the infant in a warmed incubator is indicated for an IDM with hypothermia, which is a low body temperature that can impair glucose utilization and increase oxygen consumption. However, placing the infant in a warmed incubator without proper indication can cause hyperthermia, which is a high body temperature that can lead to dehydration, electrolyte imbalance, or brain damage.
Choice D Reason: Alert the clinician immediately for orders. This is an incorrect answer that implies an urgent and unwarranted situation for an IDM with normal blood glucose. Alerting the clinician immediately for orders is indicated for an IDM with signs of distress or complications, such as apnea, cyanosis, seizures, or jaundice.
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