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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Edema, particularly peripheral edema, is a common clinical sign of preeclampsia. It results from fluid shifts due to increased vascular permeability and decreased plasma protein levels associated with the disease process.
Choice B rationale
Glycosuria, the presence of glucose in the urine, is not typically a symptom of preeclampsia. It is more commonly associated with gestational diabetes, a separate condition of pregnancy characterized by impaired glucose tolerance.
Choice C rationale
Proteinuria, the presence of significant amounts of protein in the urine (typically ≥300 mg in a 24-hour urine collection), is a hallmark sign of preeclampsia. It reflects glomerular endothelial damage and increased permeability.
Choice D rationale
Hypertension, defined as a blood pressure of ≥140/90 mmHg on two separate occasions at least 4 hours apart after 20 weeks of gestation, is a key diagnostic criterion for preeclampsia. It results from systemic vasoconstriction.
Correct Answer is A
Explanation
Choice A rationale
The latent phase of labor is the longest and often the least intense phase, characterized by mild, infrequent contractions and gradual cervical dilation (0-3 cm). During this time, the woman is typically more receptive to learning and can concentrate better, making it the ideal phase to teach non-pharmacologic pain control methods such as breathing techniques, relaxation exercises, and positioning.
Choice B rationale
The active phase of labor (4-7 cm dilation) is characterized by more frequent and intense contractions, making it harder for the laboring woman to concentrate and learn new pain management techniques. Reinforcement of previously learned techniques is more appropriate at this stage.
Choice C rationale
The transition phase (8-10 cm dilation) is the most intense and shortest phase of the first stage of labor. The woman is likely experiencing significant discomfort and may have difficulty focusing on learning new pain control methods.
Choice D rationale
The second stage of labor begins with complete cervical dilation (10 cm) and ends with the birth of the baby. The focus during this stage is on pushing and delivering the baby, making it an inappropriate time to teach non-pharmacologic pain control methods for labor.
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