A nurse is caring for a client who has rubella at the time of delivery and asks why her newborn is being placed in isolation. Which of the following responses by the nurse is appropriate?
"The child might develop encephalitis, a complication of rubella."
"Exposure to rubella will suppress the newborn's immune response."
"The newborn is at risk for developing a TORCH infection."
"The newborn might be actively shedding the virus."
The Correct Answer is D
Choice A: While rubella can lead to complications like encephalitis, this answer does not address the reason for isolation precautions for the newborn.
Choice B: While rubella can suppress the immune response in general, it does not explain the need for isolation of the newborn specifically.
Choice C: TORCH (Toxoplasmosis, Rubella, Cytomegalovirus, and Herpes) infections are a group of infections that can be transmitted from mother to fetus during pregnancy. While rubella is part of the TORCH infections, this answer does not specifically address the reason for isolation of the newborn after delivery.
Choice D: Rubella, also known as German measles, is a contagious viral infection. Newborns born to mothers with rubella can be at risk because the virus can be transmitted to them during delivery. The newborn might be actively shedding the virus, which is why isolation precautions are necessary to prevent the spread of the infection to other vulnerable newborns or individuals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A: Taking deep, cleansing breaths and breathing naturally is not the appropriate technique during the crowning phase of labor, as it can increase the risk of rapid birth and potential perineal trauma.
C: During a precipitous labor with the baby's head crowning, the nurse should encourage the mother to perform blowing or panting breaths during contractions. This technique helps to slow down the delivery process and allows the perineum to stretch gradually, reducing the risk of tearing or other trauma.
B: In the case of precipitous labor, actively pushing as hard as possible can increase the risk of rapid birth and potential complications for both the mother and the baby.
D: Slowpaced breathing patterns are not recommended during the crowning phase of labor, as they may not effectively control the birth process.
Correct Answer is D
Explanation
A. "The test will be performed if your baby's heartbeat is heard."
Incorrect: Amniocentesis is not typically performed based on whether the baby's heartbeat is heard. It is done for specific diagnostic purposes, such as genetic testing or assessing certain fetal conditions.
B. "This test will determine if your baby's lungs are mature."
Incorrect: Amniocentesis does not determine fetal lung maturity. The test involves the extraction of a small amount of amniotic fluid to analyze fetal chromosomes and identify genetic conditions.
C. "After the test, you will be given Rh immune globulin since you are Rh positive."
Incorrect: Rh immune globulin (Rhogam) is given to Rhnegative pregnant women to prevent Rh sensitization, which occurs when an Rhnegative mother is exposed to
Rhpositive fetal blood. Rhogam is not directly related to amniocentesis.
D. "This test requires the presence of an adequate volume of amniotic fluid."
Correct: Amniocentesis requires a sufficient amount of amniotic fluid around the fetus for safe and accurate testing. If there is not enough amniotic fluid, the procedure may be postponed or canceled.
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