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 {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"}}
Explanation
Rationales for Each Condition
Molar Pregnancy
- Abdominal Pain: In a molar pregnancy, the uterus enlarges disproportionately due to abnormal trophoblastic growth. This excessive expansion can cause discomfort or mild cramping.
- Blood Pressure: Molar pregnancies can be associated with gestational trophoblastic disease, which may lead to preeclampsia-like symptoms. However, this client’s blood pressure is currently within normal limits (120/78 mm Hg), so severe hypertension has not yet developed.
- Ultrasound Findings: The presence of grape-like vesicles within the uterus and the absence of a fetal heartbeat are hallmark findings of a molar pregnancy, indicating abnormal placental tissue proliferation.
- Perineal Pad Findings: The passage of small clear vesicles is a characteristic feature of a molar pregnancy, distinguishing it from other causes of vaginal bleeding in pregnancy.
Ectopic Pregnancy
- Abdominal Pain: Ectopic pregnancies often cause sharp lower abdominal pain due to tubal rupture or irritation. However, in this case, the client’s pain is mild and less suggestive of tubal rupture.
- Blood Pressure: If an ectopic pregnancy ruptures, hypotension due to internal bleeding would be expected. Since the client’s blood pressure is normal, this finding does not support an ectopic pregnancy.
- Ultrasound Findings: The absence of a fetal heartbeat and vesicular structures inside the uterus make ectopic pregnancy unlikely, as ectopic pregnancies typically occur in the fallopian tube.
- Perineal Pad Findings: Ectopic pregnancies rarely cause the passage of vesicular tissue, further suggesting that this is not an ectopic pregnancy.
Correct Answer is B
Explanation
Choice A rationale
Gonorrhea typically presents with a purulent, often thick, yellow discharge. While it can have a foul odor, the description of frothy and bubbly is less characteristic of gonorrhea. Diagnosis usually involves a cervical culture or nucleic acid amplification testing (NAAT).
Choice B rationale
Trichomoniasis, caused by the protozoan *Trichomonas vaginalis*, is characteristically associated with a large amount of yellow-green or gray, frothy, and bubbly vaginal discharge with a distinct, often foul or fishy odor. Microscopic examination of the discharge reveals the motile trichomonads for definitive diagnosis.
Choice C rationale
Chlamydia often presents with a thin or mucopurulent discharge, which may be yellowish, but it is not typically described as frothy or bubbly. Many women with chlamydia are asymptomatic. Diagnosis is usually made through NAAT of cervical or urine samples.
Choice D rationale
Syphilis in its primary stage presents with a painless chancre. Secondary syphilis can involve a generalized rash and flu-like symptoms. Vaginal discharge is not a primary characteristic of either the primary or secondary stages of syphilis. Diagnosis involves serological testing.
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