A nurse is conducting an admission assessment on a newborn. Which of the following findings should the nurse identify as an indication of sepsis?

Acrocyanosis

Hypertension

Rust-stained urine

Retractions

Answer and Explanation

The Correct Answer is D

Rationale:

A. Acrocyanosis: This is a bluish discoloration of the hands and feet that is common in newborns during the first 24 to 48 hours after birth due to immature circulation. It is not a sign of sepsis.

B. Hypertension: Newborns with sepsis are more likely to present with hypotension due to systemic infection and poor perfusion. Hypertension is not typically associated with neonatal sepsis.

C. Rust-stained urine: This discoloration can occur in newborns from urate crystals in the first few days of life and is considered a normal finding, not an indicator of infection.

D. Retractions: Retractions indicate increased work of breathing and respiratory distress, which can occur in newborn sepsis due to systemic infection affecting respiratory function. This is a concerning finding that warrants prompt evaluation.

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Correct Answer is ["A","C","E"]

Explanation

A. Assess the client’s breath sounds: Auscultation helps determine how well interventions like albuterol and oxygen are working. Detecting changes such as worsening wheezes, crackles, or diminished sounds ensures early recognition of complications. This is vital given the client’s chronic smoking history and respiratory distress.

B. Restrict the client’s fluid intake: Adequate hydration thins mucus, making it easier to clear. Unless there is heart or kidney failure, fluids should be encouraged. Restricting intake could worsen secretion retention and impair gas exchange.

C. Perform chest percussion and vibration: These techniques loosen mucus and promote clearance in clients with COPD or chronic bronchitis. Because the client has a productive cough and abnormal lung sounds, this intervention supports better airway patency. It also works well alongside bronchodilators for improved breathing.

D. Increase oxygen flow rate to 4 L/min: In clients with chronic CO₂ retention, too much oxygen can suppress respiratory drive. The current prescription of 2 L/min should be maintained unless the provider reassesses and orders changes based on ABGs.

E. Instruct the client to perform diaphragmatic breathing: This method enhances airflow to the lower lungs, reduces accessory muscle use, and improves oxygen exchange. For a COPD client, it helps conserve energy and improve ventilation. Combined with pursed-lip breathing, it strengthens respiratory efficiency.

F. Place the client in a supine position: Lying flat limits lung expansion and can worsen dyspnea in clients with lung disease. An upright or high-Fowler’s position promotes maximal ventilation and better oxygenation.

A. Remind the client to eat scheduled meals daily. B. Place the client in a supine position. C. Offer the client a blanket to keep warm. D. Speak in a loud tone when addressing the client.

Correct Answer is C

Explanation

A. Remind the client to eat scheduled meals daily: Clients nearing the end of life often have a decreased appetite and may be unable or unwilling to eat. Forcing meals can cause discomfort and is not a priority at this stage.

B. Place the client in a supine position: Lying flat can increase the risk of aspiration and respiratory discomfort. Positioning the client for comfort, often semi-Fowler’s or side-lying, is preferred.

C. Offer the client a blanket to keep warm: Clients near the end of life may experience chills or cool extremities due to decreased circulation. Providing a blanket helps maintain comfort and dignity, which is a primary goal of end-of-life care.

D. Speak in a loud tone when addressing the client: Speaking loudly is unnecessary unless the client has hearing impairment. Communication should remain calm, gentle, and respectful to provide reassurance and maintain comfort.

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A nurse is conducting an admission assessment on a newborn. Which of the following findings should the nurse identify as an indication of sepsis?

Nursing Test Bank

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