A nurse is admitting an adolescent who has rubella. Which of the following actions should the nurse take?
Administer aspirin to the client.
Isolate the client from staff who are pregnant.
Initiate airborne precautions.
Monitor for the development of Koplik spots.
The Correct Answer is B
This is because rubella is a highly contagious viral infection that can cause serious harm to the developing fetus if the pregnant person gets infected. Rubella can cause congenital rubella syndrome, which can result in hearing and vision loss, heart defects and other serious conditions in newborns.
Choice A is wrong because aspirin should not be given to children or adolescents with viral infections, as it can cause Reye’s syndrome, a rare but potentially fatal condition that affects the liver and brain.
Choice C is wrong because rubella does not require airborne precautions, which are used for diseases that can spread through very small droplets that can remain in the air for long periods of time, such as tuberculosis or measles. Rubella spreads through direct contact with saliva or mucus of an infected person, or through respiratory droplets from coughing or sneezing.
Therefore, standard and droplet precautions are sufficient to prevent transmission. Choice D is wrong because Koplik spots are a characteristic sign of measles, not rubella.
Koplik spots are small white spots that appear on the inside of the cheeks before the measles rash develops. Rubella causes a pink or red rash that usually starts on the face and moves down the body.
Normal ranges for rubella antibody tests are:
- IgM: Negative or less than 0.9 IU/mL
- IgG: Negative or less than 10 IU/mL
A positive IgM result indicates a recent or current infection, while a positive IgG result indicates a past infection or immunity from vaccination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choicea. Maternal hypoglycemia.
Choice A rationale:
Maternal hypoglycemia can lead to decreased glucose availability for the fetus, which can result in fetal bradycardia.The fetus relies on maternal glucose for energy, and a significant drop in maternal glucose levels can affect the fetal heart rate.
Choice B rationale:
Maternal fever is typically associated with fetal tachycardia rather than bradycardia.An elevated maternal temperature can increase the fetal heart rate as the fetus attempts to regulate its own temperature.
Choice C rationale:
Chorioamnionitis, an infection of the amniotic fluid and membranes, is also more commonly associated with fetal tachycardia due to the inflammatory response and fever.
Choice D rationale:
Fetal anemia can cause fetal tachycardia as the fetus compensates for the reduced oxygen-carrying capacity of the blood.Bradycardia is not a typical response to fetal anemia.
Correct Answer is A
Explanation
The nurse should ensure the state health department has been notified of the child’s Lyme disease, as it is a reportable disease in most states. Reporting helps to monitor the incidence and prevalence of Lyme disease and to implement prevention and control measures.
Choice B is wrong because antitoxin is not used to treat Lyme disease.
Antitoxin is a substance that neutralizes the effects of a toxin, such as botulism or tetanus. Lyme disease is caused by a bacterium called Borrelia burgdorferi, which can be treated with antibiotics.
Choice C is wrong because Lyme disease is not transmitted by sharing personal belongings. Lyme disease is spread to humans by the bite of infected ticks that carry the bacterium. The risk of getting Lyme disease can be reduced by avoiding tick-infested areas, wearing protective clothing, using insect repellent, and removing ticks promptly.
Choice D is wrong because skin necrosis is not a common complication of Lyme disease.
Skin necrosis is the death of skin tissue due to lack of blood supply or infection. Lyme disease can cause a characteristic skin rash called erythema migrans, which is usually circular or oval and expands over time. Other possible signs and symptoms of Lyme disease include fever, headache, fatigue, joint pain, and neurological problems.
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