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."

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. A surge of energy: Some women experience a sudden burst of energy, often referred to as a "nesting" instinct, shortly before the onset of labor.
B. Urinary retention: Urinary frequency and urgency are more common before labor, not urinary retention.
C. Decreased vaginal discharge: Before labor, there might be an increase in vaginal discharge, often thick and pinkish, known as the "bloody show."
D. Weight gain of 0.5 to 1.5 kg: Weight gain is not typically associated with the onset of labor.

A. 1 cm below the umbilicus B. 3 cm below the umbilicus C. 2 cm above the umbilicus D. 3 cm above the umbilicus

Correct Answer is C

Explanation

A. 1 cm below the umbilicus: This is too low for a client at 22 weeks of gestation.

B. 3 cm below the umbilicus: This is also too low for a client at 22 weeks of gestation.

C. 2 cm above the umbilicus: At 22 weeks of gestation, the fundus should be palpated about 2 cm above the umbilicus, which is at approximately the level of the maternal belly button.
D. 3 cm above the umbilicus: This is too high for a client at 22 weeks of gestation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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