A newborn is diagnosed with sepsis. What finding should the nurse use to suspect this health problem?
1. Irritability and flushing of the skin at 8 hours of age
2. Respiratory distress syndrome developed 48 hours after birth
3. Bradycardia and tachypnea develop when the infant is 36 hours old
4. Temperature of 97.0°F 2 hours after warming the infant from 97.4°F
4
Explanation:
1. Irritability or lethargy with pallor after the first 24 hours might indicate sepsis, especially if skin is cool and clammy.
2. Respiratory distress developing at 12 to 24 hours of age might indicate sepsis.
3. Tachycardia and periods of apnea are seen with sepsis, especially within the first 24 hours of life.
4. Temperature instability is often seen with sepsis. Fever is rare in a newborn.
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