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.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A rationale

The 1-hour glucose tolerance test is typically performed between 24 and 28 weeks of gestation to screen for gestational diabetes. This screening involves measuring the client's blood glucose level one hour after consuming a 50-gram glucose load. A normal result is generally considered to be a blood glucose level below 130-140 mg/dL.

Choice B rationale

Rubella titer is usually assessed early in pregnancy, ideally during the first prenatal visit, to determine the woman's immunity to rubella. If the woman is not immune, vaccination is typically offered postpartum to prevent infection in subsequent pregnancies, as rubella infection during pregnancy can cause serious congenital defects.

Choice C rationale

Sexually transmitted disease testing is ideally conducted at the initial prenatal visit to identify and treat any infections early in pregnancy, reducing the risk of transmission to the fetus and other complications. While repeat testing may be indicated based on risk factors, it is not a routine test specifically scheduled for the 24-week appointment for all clients.

Choice D rationale

Group B Streptococcus (GBS) culture is typically performed later in pregnancy, usually between 35 and 37 weeks of gestation, to determine if the woman is colonized with GBS. This is important for intrapartum management to prevent neonatal GBS infection.

A. I will avoid sexual intercourse until the bleeding has stopped, and for two weeks following the last evidence of bleeding. B. I will continue with my normal life after discharge. C. I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the pad. D. I will watch for the evidence of the passage of tissue.

Correct Answer is B

Explanation

Choice A rationale

Avoiding sexual intercourse is recommended in the presence of threatened abortion to prevent further uterine irritation and potential disruption of the pregnancy. Pelvic rest helps to minimize the risk of increased bleeding or complications.

Choice B rationale

Continuing with normal life after discharge is an inappropriate statement. With a threatened abortion, the client needs to understand the importance of rest and avoiding strenuous activities that could potentially exacerbate bleeding or lead to further complications. Activities that increase intra-abdominal pressure or cause physical strain should be limited.

Choice C rationale

Counting perineal pads and noting the amount and color of blood is an important instruction for monitoring the extent of bleeding. This information helps the healthcare provider assess the progression or resolution of the threatened abortion and identify any signs of increased bleeding or passage of tissue.

Choice D rationale

Watching for the evidence of the passage of tissue is crucial as it could indicate a progressing miscarriage. The client should be instructed on how to collect any passed tissue for examination by the healthcare provider to confirm the outcome of the pregnancy. .

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A nurse assesses a newborn's lab values and notes a WBC of 28,000 mm³. What action by the nurse is best?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Correct Answer is B

Explanation

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