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 97.0°F two hours after warming the infant from 97.4°F.
3. Irritability and flushing of the skin at 8 hours of age
4. Bradycardia and tachypnea develop when the infant is 36 hours old.
2
Rationale:
1. Respiratory distress developing at 12–24 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.
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