The nurse is caring for a neonate who is suspected of having sepsis. Which assessment findings would the nurse interpret as most indicative of sepsis?
Rash on face
Edematous neck
Hypothermia
Coughing
The Correct Answer is C
A. Rash on face: While some rashes may accompany infections, a localized facial rash in a neonate is nonspecific and can result from benign conditions such as erythema toxicum neonatorum, making it less indicative of systemic sepsis.
B. Edematous neck: Neck edema is uncommon in neonates and may suggest local trauma, lymphatic obstruction, or congenital anomalies rather than sepsis. It does not provide reliable evidence of systemic infection.
C. Hypothermia: Neonates with sepsis often present with hypothermia rather than fever due to immature thermoregulatory and immune systems. Persistent low body temperature, along with other signs such as lethargy or poor feeding, is a strong indicator of potential sepsis and warrants prompt evaluation and intervention.
D. Coughing: Coughing may indicate a respiratory condition, but isolated coughing is not a sensitive or specific marker for neonatal sepsis. Respiratory distress in combination with systemic signs would be more concerning.
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Related Questions
Correct Answer is D
Explanation
A. Attach the condom prior to erection: Condoms should be applied after achieving full erection to ensure proper fit and reduce the risk of breakage. Attaching the condom prematurely can lead to slippage or improper placement.
B. A condom may be reused with the same partner if ejaculation has not occurred: Condoms are single-use devices and should never be reused. Reusing increases the risk of breakage, contamination, and transmission of sexually transmitted infections.
C. Use skin lotion as a lubricant if alternatives are unavailable: Oil-based products, including skin lotion, degrade latex condoms and increase the likelihood of tearing. Only water-based or silicone-based lubricants are safe for use with latex condoms.
D. Hold the condom by the cuff upon withdrawal: Holding the base or cuff of the condom during withdrawal prevents slippage or spillage of semen, ensuring effectiveness in preventing pregnancy and reducing STI transmission.
Correct Answer is A
Explanation
A. Assess deep tendon reflexes: Magnesium sulfate depresses neuromuscular excitability, which helps prevent seizures. Monitoring deep tendon reflexes, particularly the patellar reflex, allows the nurse to evaluate therapeutic levels and detect early signs of magnesium toxicity, indicating whether the drug is effectively controlling neuromuscular activity.
B. Assess for edema: Edema is a common symptom of preeclampsia but does not directly reflect the effectiveness of magnesium sulfate in preventing seizures. While important for overall assessment, it is not a reliable indicator of seizure control.
C. Assess the client’s mucous membranes: Monitoring mucous membranes helps evaluate hydration status but does not provide information regarding the effectiveness of magnesium sulfate therapy in seizure prevention.
D. Assess the client’s skin turgor: Skin turgor is a measure of fluid status and hydration but does not indicate the therapeutic effect of magnesium sulfate on seizure control in clients with preeclampsia.
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