A client who is 38 weeks pregnant is concerned her baby might get a communicable disease before any immunizations are given.
Which physiological mechanism should the nurse use when responding to the mother's concerns?
Infants can receive antibodies through breast milk that help fight infections.
The infant's immune system may be immature in protecting against infections.
Immunity in the first months of life provides protection.
Active immunity in newborns is fully developed in the first month of life.
Correct Answer : A,B,C
Choice A rationale
Breast milk contains antibodies, specifically Immunoglobulin A (IgA), which provide passive immunity to infants and help in fighting off infections. This protective mechanism is especially important in the early months when the infant's immune system is still developing.
Choice B rationale
The immune system of a newborn is immature, particularly in its ability to produce its own antibodies. This immaturity means that newborns rely on passive immunity from the mother, either through the placenta during pregnancy or via breast milk after birth.
Choice C rationale
Infants possess passive immunity during the first few months of life, derived from maternal antibodies transferred through the placenta. This temporary immunity provides a crucial defense against infections until the infant's own immune system becomes more developed and capable of responding to pathogens.
Choice D rationale
While newborns have some level of immune function, it is not fully developed within the first month of life. Active immunity, the body's ability to produce its own antibodies in response to pathogens, takes several months to fully mature. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Benzocaine otic drops are used for pain relief and do not address the root cause of infections. Regular use without medical advice can lead to masking of symptoms and possibly delay appropriate treatment. The focus should be on preventing infections through other methods like vaccinations and avoiding irritants.
Choice B rationale
Scheduling a visit for the pneumococcal vaccine is appropriate as it can help protect against Streptococcus pneumoniae, a common cause of otitis media. Vaccinations are a preventive measure to reduce the frequency and severity of infections in infants and children.
Choice C rationale
Giving the infant the full course of antibiotics is crucial in treating and preventing recurrent infections. Incomplete antibiotic courses can lead to bacterial resistance and recurrence of infections. Caregivers must be educated on the importance of adhering to the prescribed treatment plan.
Choice D rationale
Avoiding smoking inside the house is essential as secondhand smoke is a significant risk factor for otitis media. Smoke can irritate the respiratory system and Eustachian tubes, making infants more susceptible to infections. Caregivers should be advised to maintain a smoke-free environment to protect the child's health.
Correct Answer is B
Explanation
Choice A rationale
Comparing the temperature of both legs can help identify potential circulatory issues or infections. However, temperature differences are not the most immediate concern when assessing a child with a long-leg cast. Monitoring neurovascular status, including circulation and nerve function, is more critical to ensure there are no complications such as compartment syndrome or impaired blood flow.
Choice B rationale
Monitoring capillary refill of the toes is crucial for assessing the circulatory status of the affected limb. Capillary refill time indicates how well blood is perfusing to the extremities. A delayed capillary refill time can suggest compromised circulation, which could lead to serious complications like tissue ischemia. This assessment helps ensure that the cast is not too tight and that there is adequate blood flow to the toes.
Choice C rationale
Examining for spontaneous movement is important for assessing motor function and ensuring that there is no nerve damage. However, it is not as immediate a concern as circulatory assessment. Spontaneous movement can indicate intact motor function, but circulatory compromise would need to be addressed urgently to prevent tissue damage.
Choice D rationale
Palpating femoral pulses is important for assessing the overall circulation to the lower extremities. However, in the context of a long-leg cast, it is more relevant to directly assess the area distal to the cast (such as the toes) for adequate perfusion. Checking femoral pulses alone does not provide specific information about potential compartment syndrome or tightness of the cast affecting distal circulation.
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