The nurse should recognize which of the following signs as a manifestation of sepsis in the neonate? Select all that apply.
Poor tone.
Tachypnea.
Hypothermia.
Sunken fontanel.
Hypoglycemia.
Correct Answer : A,B,C,E
Choice A rationale
Poor tone, or lethargy and hypotonia, is a common and often subtle non-specific sign of systemic illness in neonates because the central nervous system is affected by circulating bacterial toxins or poor tissue perfusion. The newborn may appear listless, "floppy," or difficult to arouse, indicating a significant compromise in neurological and physiological status secondary to sepsis.
Choice B rationale
Tachypnea, a respiratory rate greater than 60 breaths per minute, is a compensatory mechanism to combat the metabolic acidosis that often occurs in sepsis, or it may be due to a primary respiratory infection. Increased respiratory effort is a critical sign of distress in the newborn, reflecting the body's attempt to improve oxygenation and remove excess carbon dioxide.
Choice C rationale
Hypothermia (a body temperature < 36.5°C or 97.7°F) is a highly specific and often more common indicator of severe infection and sepsis in the neonate than fever. The newborn's immature thermoregulatory center can fail to mount a febrile response, and metabolic demands during sepsis can overwhelm the ability to maintain core body temperature.
Choice D rationale
A sunken fontanel usually indicates dehydration, a condition that can accompany sepsis, particularly if the infant has poor feeding or is vomiting/diarrheal. However, the signs of sepsis itself are often related to systemic inflammatory response, with a bulging fontanel being a more common sign if the neonate develops meningitis, a complication of sepsis.
Choice E rationale
Hypoglycemia (blood glucose typically < 40 mg/dL) is a frequent manifestation of neonatal sepsis. The overwhelming infection stresses the newborn's system, leading to increased metabolic rate and glucose consumption, combined with poor intake and potential liver dysfunction, which results in depleted glycogen stores and subsequent low blood sugar levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Placing non-latex gloves in the child's room is an appropriate intervention for a child suspected of having a latex allergy, such as those with spina bifida who have high exposure risk. This action ensures that all caregivers have readily available, safe supplies to prevent skin and mucous membrane contact with latex proteins, thereby minimizing the risk of triggering an allergic or anaphylactic reaction.
Choice B rationale
Checking the child's tray for allergenic foods like bananas, kiwis, avocados, and chestnuts is a crucial and appropriate intervention because these foods contain proteins that cross-react with latex proteins. This phenomenon, known as latex-fruit syndrome, necessitates dietary precautions to prevent a systemic allergic reaction in latex-sensitive individuals.
Choice C rationale
Placing a latex allergy sign on the child's door is a standard and essential safety intervention to alert all healthcare personnel, visitors, and support staff to the child's allergy status. This universal precaution helps ensure that all items brought into the room or used on the child are verified as latex-free, which is vital for preventing accidental exposure.
Choice D rationale
Removing the child's allergy armband because the parent asks would be a nursing error and an inappropriate intervention to question, as this action contradicts standard safety protocols. The allergy armband is a critical, visible identifier of a life-threatening allergy, and its removal substantially increases the risk of an accidental latex exposure and subsequent severe adverse reaction.
Correct Answer is A
Explanation
Choice A rationale
Headache is a common and early manifestation of increased intracranial pressure (ICP) in a 10-year-old child because the cranial sutures are fused, preventing skull expansion, and the rise in pressure irritates pain-sensitive structures. The headache is typically worse in the morning or awakens the child from sleep due to accumulation of carbon dioxide during sleep, which causes vasodilation.
Choice B rationale
A bulging fontanel is a sign of increased ICP seen only in infants whose anterior fontanel is still open, which is usually not the case for a 10-year-old child as the fontanel typically closes between 12 and 18 months of age. Once the fontanels are closed and sutures fused, this sign is no longer a physical possibility or indicator of increased pressure.
Choice C rationale
Tachypnea, which is an abnormally rapid breathing rate, is not typically a sign of increased ICP; in fact, severe, life-threatening ICP can lead to abnormal respiratory patterns such as Cheyne-Stokes breathing or bradypnea due to pressure on the brainstem's respiratory centers. Tachypnea is more commonly associated with hypoxia or metabolic acidosis.
Choice D rationale
An increase in head circumference, or macrocephaly, is primarily seen in infants and young children before the cranial sutures fuse (about 2 years of age) to accommodate the pressure by skull expansion. In a 10-year-old child with fused sutures, the skull cannot expand, making this finding an unreliable or late indicator of acutely increased pressure.
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