A nurse assesses a newborn's lab values and notes a WBC of 28,000 mm³. What action by the nurse is best?
Document the findings in the infant's chart.
Follow unit protocol to initiate a sepsis workup.
Take a set of vital signs and notify the provider.
Perform a heel stick for a bedside blood glucose reading.
The Correct Answer is B
Choice A rationale
While documenting findings is a crucial nursing responsibility, a white blood cell count of 28,000 mm³ in a newborn is significantly elevated. The normal range for a newborn's WBC count is typically between 9,000 to 30,000 mm³, but a value at the higher end or exceeding this range warrants further investigation to rule out infection or other underlying conditions. Simply documenting without further action could delay necessary interventions.
Choice B rationale
A WBC count of 28,000 mm³ in a newborn raises suspicion for neonatal sepsis, a serious bloodstream infection. Unit protocols for a sepsis workup typically involve obtaining blood cultures, a complete blood count with differential, and potentially a lumbar puncture and chest X-ray to identify the source and extent of infection. Prompt initiation of these measures is critical for timely diagnosis and treatment, improving the newborn's prognosis.
Choice C rationale
Taking vital signs is a standard nursing assessment, but in the presence of an abnormal lab value suggestive of a serious condition like sepsis, it is insufficient as the sole action. While changes in vital signs can indicate infection, they may not be present in the early stages. Notifying the provider is necessary, but initiating a sepsis workup concurrently based on unit protocol allows for quicker diagnostic evaluation.
Choice D rationale
A heel stick for a bedside blood glucose reading is indicated for assessing hypoglycemia, a common concern in newborns, particularly those at risk. However, it does not directly address the significantly elevated WBC count. While infection can sometimes affect blood glucose levels, this test would not provide information about the potential underlying cause of the leukocytosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Rapid plasma regain is not a standard laboratory test associated with hyperemesis gravidarum. Hyperemesis gravidarum involves significant fluid and electrolyte losses, but rapid plasma regain is not a specific indicator of this condition.
Choice B rationale
A urine culture is used to detect the presence of bacteria in the urine, typically to diagnose a urinary tract infection. While dehydration from hyperemesis gravidarum can increase the risk of a UTI, a urine culture is not a primary anticipated laboratory test for hyperemesis itself.
Choice C rationale
Prothrombin time (PT) is a blood test that measures how long it takes blood to clot. It is used to assess coagulation and is not directly related to the metabolic and electrolyte imbalances caused by hyperemesis gravidarum.
Choice D rationale
Urine ketones are a byproduct of fat breakdown for energy, which occurs when the body is not getting enough glucose. In hyperemesis gravidarum, persistent vomiting can lead to dehydration and starvation, forcing the body to break down fat for energy, resulting in ketonuria (ketones in the urine).
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Upon reviewing the client’s medical record, the nurse determines that the client is at risk for developing choriocarcinoma and thyrotoxicosis.
Rationale for correct answers
Choriocarcinoma is a malignant form of gestational trophoblastic disease (GTD) that arises from a molar pregnancy, as evidenced by grape-like vesicles seen on ultrasound and excessively elevated beta-hCG (normal in pregnancy: up to 100,000 mIU/mL by late first trimester). This condition can lead to metastases if not diagnosed and treated promptly.
Thyrotoxicosis occurs due to excess beta-hCG, which stimulates thyroid hormone production. This is supported by the slightly elevated free T4 levels, a common feature of molar pregnancy-related hyperthyroidism.
Rationale for incorrect Response 1 options
- Preterm labor: The client is at 20 weeks with no contractions noted, and cervical changes are not reported.
- Placenta previa: Characterized by painless bright red bleeding later in pregnancy; this client has dark brown discharge consistent with molar pregnancy.
- Cardiac arrhythmia: No evidence of electrolyte abnormalities or arrhythmogenic conditions such as hyperkalemia.
Rationale for incorrect Response 2 options
- Preeclampsia: Normal blood pressure (≥140/90 mm Hg would be concerning); no proteinuria.
- Urinary tract infection: No leukocytes, nitrites, or dysuria reported.
- Hypoglycemia: Normal serum glucose levels; vomiting history does not indicate hypoglycemia.
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