As relates to rubella and Rh issues, nurses should be aware that:.

Breastfeeding mothers cannot be vaccinated with the live attenuated rubella virus.

Women should be warned that the rubella vaccination is teratogenic and that they must avoid pregnancy for 1 month after vaccination.

Rh immune globulin is safely administered intravenously because it cannot harm a nursing infant.

Rh immune globulin boosts the immune system and thereby enhances the effectiveness of vaccinations.

Answer and Explanation

The Correct Answer is B

The presence or absence of anxiety is a noninvasive assessment that the RN would perform to evaluate the patient’s psychological status and possible signs of hypovolemic shock.

Anxiety can indicate reduced cerebral perfusion due to blood loss and low blood pressure.

Choice A is wrong because pulse oximetry is a noninvasive assessment that the RN would perform to measure the oxygen saturation of the patient’s blood, not the circulatory status.

Choice B is wrong because heart sounds are a noninvasive assessment that the RN would perform to auscultate the cardiac rhythm and rate of the patient, not the circulatory status.

Choice C is wrong because arterial pulses are a noninvasive assessment that the RN would perform to palpate the strength and quality of the patient’s peripheral pulses, not the circulatory status.

Choice D is wrong because skin color, temperature, and turgor are noninvasive assessments that the RN would perform to observe the skin integrity and hydration of the patient, not the circulatory status.

Normal ranges for pulse oximetry are 95% to 100%, for heart rate, are 60 to 100 beats per minute, and for blood pressure are 120/80 mmHg.

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Correct Answer is D

Explanation

This pattern is called periodic breathing and it is characterized by 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration. It is a normal phenomenon that occurs primarily in premature infants of more than 24 hours of age. It is usually not of pathologic significance and does not require intervention.

Choice A is wrong because sleep or wakeful apnea is defined as a cessation of breathing for more than 20 seconds or less than 20 seconds with bradycardia or cyanosis.

Choice B is wrong because severe swings in blood pressure are not associated with periodic breathing, but rather with intraventricular hemorrhage or patent ductus arteriosus.

Choice C is wrong because trying to maintain a neutral thermal environment does not affect the respiratory pattern of premature infants.

Normal ranges for respiratory rate in premature infants are 40 to 60 breaths per minute. Normal ranges for oxygen saturation in premature infants are 88% to 92%.

A. Respiratory rate of 36 breaths/minute at rest B. Appetite slowly increasing C. Temperature above 37.7° C (100° F) D. New, frequent coughing E. Turning blue or bluer than normal

Correct Answer is ["C","D","E"]

Explanation

The parents should notify the physician if the infant has a temperature above 37.7° C (100° F), new frequent coughing, or turning blue or bluer

than normal. These are signs of infection, respiratory distress, or cyanosis, which could indicate complications after cardiac surgery.

Choice A is wrong because a respiratory rate of 36 breaths/minute at rest is within the normal range for an infant.

Choice B is wrong because an appetite slowly increasing is a positive sign of recovery and does not require immediate attention.

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As relates to rubella and Rh issues, nurses should be aware that:.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Premature infants who exhibit 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration are:.

Correct Answer is D

Explanation

A nurse is conducting discharge and teaches parents about the care of their infant after cardiac surgery. The nurse instructs the parents to notify the physician if the conditions occur. (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

As relates to rubella and Rh issues, nurses should be aware that:.

It is now recommended that children with asthma who are taking long-term inhaled steroids should be assessed frequently to monitor for increased risk of:

Which factor is most important in predisposing toddlers to frequent infections such as otitis media, tonsillitis, and upper respiratory tract infections?

A woman is in her seventh month of pregnancy. She has been reporting nasal congestion and occasional epistaxis. The nurse suspects that:

A school-age child is admitted in vaso-occlusive sickle cell crisis. The child’s care should include which intervention? (Select all that apply.)

Which intervention should be included in the plan of care for an infant with the nursing diagnosis of Excess Fluid Volume related to congestive heart failure?

What is the priority nursing goal for a 14-year-old diagnosed with Graves’ disease?

During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is:.