A nurse is assisting with the care of a client on their first prenatal visit. Which of the following screenings require follow up intervention?
Rubella titer nonimmune
Negative varicella titer
Positive Rh factor
Positive serologic test for syphilis
The Correct Answer is D
A) Rubella titer nonimmune: A nonimmune rubella titer indicates that the client is not immune to rubella, which is a common finding in many pregnant women. However, rubella vaccination is not given during pregnancy because the vaccine is a live virus. The client will typically be vaccinated postpartum. Follow-up would be required, but it is not an urgent concern during the pregnancy itself.
B) Negative varicella titer: A negative varicella titer means the client is not immune to chickenpox, which is a concern because varicella can cause serious complications during pregnancy. However, similar to rubella, the varicella vaccine is contraindicated during pregnancy, and vaccination would be given postpartum. This requires follow-up after delivery but does not require urgent intervention during the pregnancy.
C) Positive Rh factor: The Rh factor is a blood type characteristic, but what is typically more concerning is the Rh incompatibility, which occurs when a Rh-negative mother carries a Rh-positive baby. A positive Rh factor is not a problem for the client themselves but could be important if the father is Rh-positive. If there is concern for Rh incompatibility, the nurse would monitor for the development of Rh sensitization and administer Rh immunoglobulin (RhoGAM) if needed. This does not require urgent intervention unless Rh incompatibility is confirmed.
D) Positive serologic test for syphilis: A positive test for syphilis requires immediate follow-up intervention. Syphilis is a sexually transmitted infection that can cause serious complications during pregnancy, including miscarriage, stillbirth, preterm birth, and congenital syphilis. Treatment with penicillin is recommended to prevent transmission to the baby and to treat the infection in the mother. A positive serologic test for syphilis warrants prompt intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Rubber duck:
A rubber duck may be a suitable toy for a 2-month-old infant during bath time, but it is not considered the most developmentally appropriate for this age. At 2 months, infants are beginning to focus their vision on objects but have limited ability to manipulate toys. Toys such as a rubber duck do not provide the most stimulating developmental experience for an infant at this age.
B) Nesting cups:
Nesting cups are not the most appropriate for a 2-month-old infant. At this stage of development, babies are still in the early stages of hand-eye coordination and grasping skills. Nesting cups are more suitable for older infants (around 6-9 months) who are beginning to explore stacking, nesting, and grasping objects with more precision.
C) Crib mobile:
A crib mobile is an excellent developmentally appropriate toy for a 2-month-old infant. At this age, infants are developing visual tracking skills and are attracted to high-contrast patterns or moving objects. A crib mobile offers visual stimulation and can help an infant focus their eyes on objects, encouraging visual tracking and early sensory development. It is also safe for use in the crib environment.
D) Plastic keys:
Plastic keys can be a good toy for older infants as they begin developing their grasping and mouthing skills, but a 2-month-old infant is not yet able to hold objects or bring them to their mouth with coordination. Toys like these would not offer much benefit in terms of developmental stimulation at this age.
Correct Answer is A
Explanation
A) "I will stop what I am doing and lie down.": This is the correct response. When a client with stable angina experiences chest pain, they should stop any physical activity and rest in a comfortable position, preferably lying down. This helps reduce the heart’s workload and decrease the demand for oxygen, which can relieve the pain. Rest is important before taking any further action.
B) "I will take two 325 milligram aspirin tablets at the same time.": While aspirin can help reduce blood clot formation in some cases of chest pain, the recommended dosage is typically one 81-325 mg aspirin, not two 325 mg tablets. Taking two large doses may lead to an overdose or unwanted side effects. Additionally, this is not the immediate intervention for stable angina pain, which typically responds to rest and nitroglycerin.
C) "I will hold my breath and bear down.": This technique, known as the Valsalva maneuver, can increase intrathoracic pressure and slow the heart rate, but it is not recommended to relieve chest pain in stable angina. In fact, it could increase stress on the heart and worsen the symptoms. This maneuver is used in specific situations, such as slowing a rapid heart rate, not for chest pain relief.
D) "I will call the provider after taking one dose of nitroglycerin.": The client should first try nitroglycerin for chest pain as prescribed, and if the pain doesn’t resolve after one dose (or if it worsens), they should seek medical attention. However, in the case of stable angina, it's more appropriate to call the provider if the chest pain persists despite rest and nitroglycerin, not immediately after the first dose.
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