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 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 B
Explanation
Choice A rationale
The stepping reflex, also known as the walking or dancing reflex, is elicited by holding the infant upright with their feet touching a flat surface. The infant will make stepping or dancing movements. This is not elicited by stroking the lateral sole of the foot.
Choice B rationale
The Babinski reflex is elicited by stroking the lateral sole of the infant's foot from the heel upward and across the ball of the foot. A positive Babinski sign is characterized by dorsiflexion of the great toe and fanning out of the other toes. This reflex is normal in infants and typically disappears by 12 to 24 months of age.
Choice C rationale
The tonic neck reflex, also known as the fencing reflex, is elicited by turning the infant's head to one side. The arm and leg on the turned side extend, while the arm and leg on the opposite side flex. Stroking the sole of the foot does not elicit this reflex.
Choice D rationale
The plantar grasp reflex is elicited by placing a finger or object across the base of the infant's toes. The toes will curl downward and grasp the object. This reflex is different from the response elicited by stroking the lateral sole of the foot. .
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