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 C
Explanation
The correct answer is c. Remove the cap and place it sterile-side up on a clean surface.
Choice A rationale:
Placing sterile gauze over areas of spilled solution within the sterile field is incorrect. If solution is spilled within the sterile field, the entire field should be considered contaminated and a new sterile field should be set up
Choice B rationale:
Holding the irrigation solution bottle with the label facing away from the palm of the hand is incorrect. The label should face the palm of the hand to avoid contamination of the sterile field
Choice C rationale:
Removing the cap and placing it sterile-side up on a clean surface is correct. This ensures that the sterile side of the cap remains sterile and can be used to recap the bottle after pouring the solution
Choice D rationale:
Holding the bottle in the center of the sterile field when pouring the solution is incorrect. The bottle should be held over the edge of the sterile field to avoid contamination of the field if solution spills
Correct Answer is A
Explanation
The correct answer is choicea. Swelling of the face.
Choice A rationale:
Swelling of the face can be a sign of preeclampsia, a serious condition that requires immediate medical attention.Preeclampsia can lead to complications for both the mother and the baby if not managed properly.
Choice B rationale:
Urinary frequency is a common symptom during pregnancy due to hormonal changes and the growing uterus pressing on the bladder.It is generally not a cause for concern unless accompanied by other symptoms like pain or burning during urination.
Choice C rationale:
Faintness upon rising, also known as orthostatic hypotension, is common in pregnancy due to changes in blood circulation.It can often be managed by rising slowly and ensuring adequate hydration.
Choice D rationale:
Bleeding gums are common during pregnancy due to hormonal changes that increase blood flow to the gums, making them more sensitive and prone to bleeding.Good oral hygiene can help manage this symptom.
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