A client who is 38 weeks pregnant is concerned her baby might get a communicable disease before any immunizations are given.
Which physiological mechanism should the nurse use when responding to the mother's concerns?
Infants can receive antibodies through breast milk that help fight infections.
The infant's immune system may be immature in protecting against infections.
Immunity in the first months of life provides protection.
Active immunity in newborns is fully developed in the first month of life.
Correct Answer : A,B,C
Choice A rationale
Breast milk contains antibodies, specifically Immunoglobulin A (IgA), which provide passive immunity to infants and help in fighting off infections. This protective mechanism is especially important in the early months when the infant's immune system is still developing.
Choice B rationale
The immune system of a newborn is immature, particularly in its ability to produce its own antibodies. This immaturity means that newborns rely on passive immunity from the mother, either through the placenta during pregnancy or via breast milk after birth.
Choice C rationale
Infants possess passive immunity during the first few months of life, derived from maternal antibodies transferred through the placenta. This temporary immunity provides a crucial defense against infections until the infant's own immune system becomes more developed and capable of responding to pathogens.
Choice D rationale
While newborns have some level of immune function, it is not fully developed within the first month of life. Active immunity, the body's ability to produce its own antibodies in response to pathogens, takes several months to fully mature. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Telling the child that you're glad the mother explained the procedure doesn't provide the child with an opportunity to express their understanding or concerns. It is important to engage the child directly to understand what they know and how they feel about the operation, rather than relying solely on what the parent has communicated.
Choice B rationale
Asking the child to explain what an operation is allows the nurse to gauge the child's understanding and provides an opportunity to correct any misconceptions. This approach also encourages open communication and helps the child feel more involved and informed about their own care, which can reduce anxiety.
Choice C rationale
Reassuring the child that the hospital staff will take very good care of them is comforting, but it doesn't address the child's need for information and understanding about the operation. While it's important to provide reassurance, the primary focus should be on ensuring the child comprehends what will happen.
Choice D rationale
Directly asking the child if they are scared might lead to a yes or no answer, and doesn't necessarily encourage them to share their specific fears or concerns. It is more effective to ask open-ended questions that allow the child to express their feelings in more detail, which can then be addressed by the nurse.
Correct Answer is A
Explanation
Choice A rationale
Non-nutritive sucking, such as with a pacifier, can be soothing and calming for infants. It helps in the development of oral motor skills and provides comfort during enteral feedings, ensuring that the infant’s need for sucking is met even when they are not feeding.
Choice B rationale
Sterile technique is essential for preventing infections during invasive procedures, but enteral feeding typically does not require such stringent measures. Clean technique is usually sufficient unless the infant has a compromised immune system or other specific medical conditions requiring sterile precautions.
Choice C rationale
While verifying tube placement is critical, it is often done using methods such as pH testing of gastric contents or external marking rather than routine x-rays. Overuse of x-rays exposes infants to unnecessary radiation. X-rays are used primarily when other methods are inconclusive.
Choice D rationale
Instituting physical therapy for a one-month-old infant would not be developmentally appropriate as their primary needs are centered around nutrition, comfort, and growth. Physical therapy is more relevant for older children with developmental or mobility issues rather than infants receiving enteral feedings. .
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