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) "You owe it to your mother to take care of her now that she needs you.":
This response is not supportive and places unnecessary guilt on the son. Caregiving for a loved one with Alzheimer's disease is demanding, and expecting the son to provide care without considering his own needs is unrealistic. Guilt-tripping him may lead to burnout, as it does not acknowledge the emotional and physical strain of caregiving.
B) "You should think about placing your mother in a long-term care facility.":
While this may be a viable option for some families, this statement does not acknowledge the son’s emotional struggle or immediate need for support. Suggesting a long-term care facility may be premature without exploring other options and may cause the son to feel as though he is being pushed into a decision he is not ready to make.
C) "Let me give you some information about respite care for your mother.":
This is the most appropriate response. Respite care provides temporary relief for family caregivers, allowing them time to rest and recharge. It is a supportive approach that acknowledges the son’s exhaustion and provides him with a helpful resource. Respite care can alleviate caregiver burnout and help maintain the quality of care for the client.
D) "I think you should find other family members who could help your mother.":
While involving other family members can be helpful, this response does not provide immediate support or acknowledge the son’s current feelings of exhaustion. Suggesting that he simply find other family members may come across as dismissive of his current emotional state and may not offer the practical help he needs at this moment.
Correct Answer is C
Explanation
A) Oucher scale: The Oucher scale is a pain assessment tool that is appropriate for children ages 3 to 12 years. It uses a series of photos depicting facial expressions that range from no pain to extreme pain. While useful for older children, it is not the most appropriate choice for an 8-month-old infant.
B) Visual Analog scale: The Visual Analog scale is typically used for children and adults who are able to understand and use numerical ratings or visual representations of pain. Since an 8-month-old infant is unable to verbally communicate or use this scale, it would not be suitable for evaluating their pain.
C) FLACC scale: The FLACC scale (Face, Legs, Activity, Cry, Consolability) is designed for infants and young children who are unable to verbally communicate their pain. It is ideal for assessing the pain levels of infants, as it evaluates observable behaviors like facial expressions, leg movement, and crying, which are indicators of pain in nonverbal children.
D) FACES pain scale: The FACES pain scale is typically used for children as young as 3 years old, but it requires the child to be able to identify and select facial expressions that correspond to their pain. An 8-month-old infant would not be able to engage with this scale, as it requires some cognitive development and understanding of emotional expressions.
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