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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Assess the parents’ anxiety level and readiness to learn. This is because the nurse needs to evaluate the parent’s emotional state and their ability to comprehend and retain information before providing any teaching.
The nurse should also consider the parent'slearning style, cultural background, and literacy level.
Choice B is wrong because gathering literature for the parents is not the first action. The nurse should first assess the parents’ needs and preferences and then select appropriate materials that match their level of understanding and language.
Choice C is wrong because securing a quiet place for teaching is not the first action. The nurse should first assess the parents’ readiness to learn and then choose a suitable environment that minimizes distractions and promotes comfort.
Choice D is wrong because discussing the plan with the nursing team is not the first action. The nurse should first assess the parents’ anxiety level and readiness to learn and then collaborate with other health care professionals to provide consistent and accurate information.
Correct Answer is D
Explanation
choice D. Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia. This is because a macrosomic infant (a newborn who’s much larger than average) is at risk of developing low blood sugar levels after birth, especially if the mother has diabetes. Hypoglycemia can cause neurological damage in the newborn, so it is important to detect and treat it promptly.
Choice A is wrong because leaving the infant in the room with the mother without monitoring the blood glucose levels may miss signs of hypoglycemia and delay treatment.
Choice B is wrong because taking the infant immediately to the nursery may separate the infant from the mother and interfere with breastfeeding, which can help prevent hypoglycemia.
Choice C is wrong because performing a gestational age assessment to determine whether the infant is large for gestational age is not urgent and does not address the risk of hypoglycemia.
Normal ranges for blood glucose levels in term infants are 2.6 mmol/L or higher at any time. A blood glucose level of 2.5 mmol/L or less is considered hypoglycemic.
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