Practice Question
A nurse is caring for a newborn.
Answer Choices:
Rationale:
Neurologic: Irritability
🔷 Irritability in a newborn—especially with prolonged rupture of membranes—can be an early sign of neonatal infection/sepsis.
🔷 It reflects possible CNS irritation, systemic illness, or metabolic stress that requires prompt evaluation.
🔷 This symptom becomes more concerning when paired with abnormal labs like WBC 40,000/mm³ and CRP 2.5 mg/dL.
🔷 Newborns can deteriorate quickly, so behavioral changes are treated as early warning signs.
🔷 Reporting supports rapid assessment and timely initiation of testing or treatment (e.g., cultures, antibiotics).
Axillary Temperature: 36.2°C (97.2°F)
🔷 A temperature of 36.2°C is low for a newborn and can indicate cold stress or sepsis.
🔷 Newborns often show infection as hypothermia rather than fever, making this particularly important.
🔷 Cold stress increases oxygen consumption and can worsen respiratory distress and metabolic stability.
🔷 With the additional risk factor of prolonged rupture of membranes, this temperature requires provider notification.
🔷 Prompt intervention helps prevent complications like hypoglycemia, acidosis, and worsening respiratory effort.
Cardiopulmonary: Respiratory Rate 80/min
🔷 A respiratory rate of 80/min is tachypnea (normal newborn RR ≈ 30–60/min).
🔷 Tachypnea indicates respiratory distress and can be associated with infection, aspiration, or transitional problems.
🔷 When RR is this high, the newborn may have difficulty coordinating feeding and breathing, increasing risk of aspiration.
🔷 This finding is especially urgent when combined with expiratory grunting, which signals increased work of breathing.
🔷 The provider must evaluate quickly to prevent progression to respiratory failure or worsening hypoxemia.
Apical Heart Rate: 158/min
🔷 A heart rate of 158/min is at the upper end of normal for a newborn but becomes concerning with concurrent signs of stress.
🔷 Tachycardia may reflect respiratory distress, infection, or cold stress, all of which are present in this scenario.
🔷 When paired with tachypnea and hypothermia, it suggests systemic compensation and possible clinical deterioration.
🔷 Provider evaluation is needed to determine whether this is transitional or part of a worsening condition like sepsis.
🔷 Early reporting supports timely interventions to stabilize oxygenation and temperature, which often improves heart rate.
Gastrointestinal: Abdomen hard and distended
🔷 A hard, distended abdomen in a newborn is abnormal and can indicate bowel obstruction, necrotizing enterocolitis (NEC), or severe GI pathology.
🔷 Distention suggests impaired motility or inflammation, which can progress rapidly to perforation or sepsis.
🔷 This finding is especially concerning when paired with systemic signs like tachypnea and abnormal inflammatory labs.
🔷 A firm abdomen can also compromise breathing by limiting diaphragmatic expansion, worsening respiratory distress.
🔷 Immediate provider notification is needed for possible imaging, bowel rest, and urgent intervention.
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This question is from RN Maternal Newborn 2023 Dec 17 which contains 70 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Maternal & Newborn Care
- Answer Choices: 1