Author Question: The newborn has been diagnosed with sepsis. What indications would lead the nurse to suspect this ... (Read 60 times)

jrubin · **on:** Jun 28, 2018

The newborn has been diagnosed with sepsis. What indications would lead the nurse to suspect this condition?

1. Respiratory distress syndrome developed 48 hours after birth.
2. Temperature of 97.0F two hours after warming the infant from 97.4F.
3. Irritability and flushing of the skin at 8 hours of age
4. Bradycardia and tachypnea develop when the infant is 36 hours old.

Question 2

The primiparous client at 40 weeks' gestation reports to the nurse that she has had increased pelvic pressure and increased urinary frequency. Which response by the nurse is best?

1. Unless you have pain with urination, we don't need to worry about it.
2. These symptoms usually mean the baby's head has descended further.
3. Come in for an appointment today and we'll check everything out.
4. This might indicate that the baby is no longer in a head down position.

softEldritch · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

2
Rationale:
1. Respiratory distress developing at 1224 hours of age might indicate sepsis.
2. Temperature instability is often seen with sepsis. Fever is rare in a newborn.
3. Irritability or lethargy with pallor after the first 24 hours might indicate sepsis, especially if skin is cool and clammy.
4. Tachycardia and periods of apnea are seen with sepsis, especially within the first 24 hours of life.

Answer to Question 2

2
Rationale:
1. Increased pelvic pressure and urinary frequency are premonitory signs of labor. These are not signs of a urinary tract infection.
2. This is the best response because it most directly addresses what the client has reported. Increased pelvic pressure and urinary frequency are premonitory signs of labor.
3. There is no need for an additional appointment, as increased pelvic pressure and urinary frequency are premonitory signs of labor.
4. The client is experiencing premonitory signs of labor; the fetus changing to a breech presentation would be experienced as fetal movement that was formerly felt in the upper abdomen but now is down in the pelvis.