Practice Question
A nurse is caring for a newborn.
Answer Choices:
Rationale:
Neurologic — Irritability
🔷 Irritability in the first hours of life is a red flag for systemic infection/meningitis, especially with prolonged rupture of membranes (PROM) and elevated inflammatory markers (WBC 40,000/mm³, CRP 2.5 mg/dL).
🔷 Neonates often show neurobehavioral changes (irritability, lethargy, poor feeding) instead of fever when septic.
🔷 It can also accompany hypoglycemia, but the glucose here is borderline‑acceptable (45 mg/dL); the sepsis context makes infection more likely.
🔷 Report promptly so a full sepsis workup (blood/urine cultures ± lumbar puncture) and empiric antibiotics can be initiated.
Axillary temperature — 36.2 °C (97.2 °F)
🔷 Normal newborn temperature range is 36.5–37.5 °C; hypothermia is a classic presentation of neonatal sepsis.
🔷 Low temperature worsens pulmonary transition, increases oxygen consumption, and can precipitate hypoglycemia.
🔷 With PROM and abnormal labs, this low temp should be treated as infectious until proven otherwise.
🔷 Report and institute thermoregulation (skin‑to‑skin or radiant warmer) while sepsis evaluation proceeds.
Cardiopulmonary — Respiratory rate 80/min
🔷 Normal neonatal RR is 30–60/min; tachypnea (80) indicates respiratory distress.
🔷 In the setting of PROM and inflammatory labs, causes include pneumonia/sepsis (in addition to TTN or RDS).
🔷 Tachypnea compromises feeding and risks aspiration; it warrants immediate assessment and oxygen support as needed.
🔷 Report for CXR, blood gas, and escalation of care (e.g., CPAP if indicated).
Cardiopulmonary — Expiratory grunting
🔷 Grunting is a compensatory maneuver to maintain functional residual capacity, signaling alveolar instability or fluid‑filled lungs.
🔷 In a term newborn with infection risk, grunting strongly suggests pneumonia/sepsis‑related respiratory disease.
🔷 Grunting plus tachypnea requires urgent respiratory support and diagnostic evaluation.
🔷 Report immediately; anticipate oxygen, continuous monitoring, and sepsis management.
Gastrointestinal — Abdomen hard and distended
🔷 A firm, distended abdomen is abnormal and concerning for ileus, bowel obstruction, or necrotizing enterocolitis (NEC)—conditions that can be precipitated or worsened by sepsis.
🔷 Distension paired with respiratory distress can impair ventilation and indicates systemic illness.
🔷 Requires the provider’s evaluation for abdominal imaging, NPO status, and gastric decompression (OG/NG) as indicated.
🔷 Early recognition prevents perforation and hemodynamic compromise.
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This question is from RN Maternal Newborn 2023 Exam which contains 69 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