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 D
Explanation
A) Place the bedside table 2 feet away from the bed: This is not recommended for a client at risk for falls. The bedside table should be within reach of the client to avoid the need for excessive movement, which could increase the risk of a fall, especially if the client is unsteady or disoriented. Ideally, the bedside table should be placed within arm’s reach for convenience and safety.
B) Keep lighting in the home dim: Dim lighting increases the risk of falls by making it harder for the client to see obstacles and navigate safely. It is important to ensure that lighting is bright enough to illuminate walking areas, hallways, and other areas that might present a fall risk.
C) Place area rugs on slick floor surfaces: Area rugs on slick surfaces are hazardous as they can cause tripping or slipping, increasing the risk of a fall. It is best to remove rugs or ensure they are securely fastened to prevent them from sliding. Non-slip rugs or floor mats can be used, but they should not be placed on slick surfaces.
D) Move the client's bed to the main floor of the house: Moving the client's bed to the main floor is a good safety measure, especially if the client has difficulty navigating stairs. This reduces the need for the client to climb stairs, which can be dangerous and increase the risk of falls. Having the bed on the main floor ensures that the client can easily access their sleeping area without the risk of falling on stairs.
Correct Answer is D
Explanation
A) "I should eat a high fat diet for several weeks": After a laparoscopic cholecystectomy, the client is typically advised to avoid high-fat foods for a period of time as the body adjusts to the absence of the gallbladder. High-fat foods can trigger discomfort, nausea, or diarrhea. Therefore, recommending a high-fat diet is not appropriate post-surgery.
B) "I should expect to have diarrhea until my diet changes": Diarrhea is a possible side effect following gallbladder removal, particularly due to the changes in bile flow. However, the client should not expect diarrhea indefinitely. Over time, the digestive system adjusts, and with dietary modifications, diarrhea often resolves. The client should not assume this will persist unless directed by the healthcare provider.
C) "I should expect to have nausea for several days": Nausea is not typically expected to last for several days following a laparoscopic cholecystectomy. While mild nausea can occur shortly after surgery, it should subside within a short time. If nausea persists beyond this period, the client should notify their healthcare provider for further evaluation.
D) "I should leave my steri-strips on until they fall off.": Steri-strips are used to help close the incision site and should remain in place until they naturally fall off, which usually occurs within 7–10 days after surgery. This statement indicates that the client understands the proper care for their incision site. It is important not to remove them prematurely to avoid disrupting the healing process.
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