A nurse is caring for a toddler who has impetigo. Which of the following actions should the nurse take?
Inform the caregiver that it is okay to use the same towels.
Request the provider to prescribe an antiviral medication.
Place the toddler on droplet precautions.
Prevent the toddler from scratching their skin by using elbow restraints.
The Correct Answer is D
Rationale:
A. Inform the caregiver that it is okay to use the same towels: Sharing towels can spread impetigo, which is a highly contagious bacterial skin infection. Families should be instructed to use separate towels, washcloths, and linens to reduce the risk of cross-contamination.
B. Request the provider to prescribe an antiviral medication: Impetigo is caused by bacteria such as Staphylococcus aureus or Streptococcus pyogenes, not viruses. Antibacterial agents, not antivirals, are the appropriate treatment for managing this condition.
C. Place the toddler on droplet precautions: Impetigo primarily spreads through direct contact with lesions or contaminated objects, not respiratory droplets. Standard precautions with contact isolation are typically used rather than droplet precautions.
D. Prevent the toddler from scratching their skin by using elbow restraints: Scratching can worsen impetigo lesions and lead to further bacterial spread or secondary infection. Using soft restraints like elbow splints can safely discourage scratching and promote healing while preventing the infection from spreading.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "Store ready-to-feed formula at room temperature for up to 4 hours.": Ready-to-feed formula should be used promptly or refrigerated if not used immediately. Leaving it at room temperature for up to 4 hours increases the risk of bacterial growth and contamination.
B. "Warm the bottle of formula by immersing it in a container of warm tap water.": This is a safe and recommended method to gently warm formula without overheating or creating hot spots that could burn the infant’s mouth.
C. "Keep open cans of concentrated formula uncovered and refrigerated.": Open cans of concentrated formula should always be covered to prevent contamination and should be refrigerated promptly after opening.
D. "Discard any formula left in the bottle within 2 hours after beginning feeding.": Formula left in the bottle after feeding should be discarded within 1 to 2 hours to prevent bacterial growth that can cause illness in the infant. This practice helps ensure feeding safety.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}
Explanation
Rationale:
• Monitor fetal heart rate: Continuous monitoring is essential after epidural placement to detect changes in fetal status. Minimal variability and early decelerations could indicate emerging fetal distress. Early detection guides timely intervention.
• Assist with administration of ampicillin IV: The client is GBS positive and in active labor with ruptured membranes. IV antibiotics reduce the risk of neonatal infection. Prompt administration is key for prophylaxis.
• Request a prescription for ephedrine: Epidural anesthesia may cause maternal hypotension, which decreases placental perfusion. Ephedrine helps maintain blood pressure. This supports uteroplacental circulation and fetal oxygenation.
• Place the client in left lateral position: This improves uterine perfusion and helps relieve vena cava compression. It is especially important after epidural anesthesia. It also supports better fetal oxygenation during decelerations.
• Decrease the IV flow rate: IV fluids help counteract hypotension that may result from epidural use. Reducing the rate would worsen perfusion and blood pressure. This could compromise fetal oxygen delivery.
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