A nurse is admitting an adolescent who has rubella. Which of the following actions should the nurse take?
Administer aspirin to the client.
Isolate the client from staff who are pregnant.
Initiate airborne precautions.
Monitor for the development of Koplik spots.
The Correct Answer is B
This is because rubella is a highly contagious viral infection that can cause serious harm to the developing fetus if the pregnant person gets infected. Rubella can cause congenital rubella syndrome, which can result in hearing and vision loss, heart defects and other serious conditions in newborns.
Choice A is wrong because aspirin should not be given to children or adolescents with viral infections, as it can cause Reye’s syndrome, a rare but potentially fatal condition that affects the liver and brain.
Choice C is wrong because rubella does not require airborne precautions, which are used for diseases that can spread through very small droplets that can remain in the air for long periods of time, such as tuberculosis or measles. Rubella spreads through direct contact with saliva or mucus of an infected person, or through respiratory droplets from coughing or sneezing.
Therefore, standard and droplet precautions are sufficient to prevent transmission. Choice D is wrong because Koplik spots are a characteristic sign of measles, not rubella.
Koplik spots are small white spots that appear on the inside of the cheeks before the measles rash develops. Rubella causes a pink or red rash that usually starts on the face and moves down the body.
Normal ranges for rubella antibody tests are:
- IgM: Negative or less than 0.9 IU/mL
- IgG: Negative or less than 10 IU/mL
A positive IgM result indicates a recent or current infection, while a positive IgG result indicates a past infection or immunity from vaccination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should include this information in the teaching because suctioning is often needed to keep the tracheostomy tube and opening free from extra mucus and secretions that come from the lungs and tissue around the stoma. Suctioning can help prevent the tube from becoming plugged and improve breathing.
Choice A is wrong because the nondisposable tracheostomy tube does not need to be changed daily. It can be changed every 1 to 3 months, depending on the type of tube.
Choice C is wrong because the tracheostomy dressing should be changed using sterile technique, not clean technique, to prevent infection.
Choice D is wrong because the tracheostomy tube should not be secured with ties at the back of the neck. The ties should be fastened at the front or side of the neck, and they should be snug but not too tight.
Correct Answer is B
Explanation
This action demonstrates the nurse’s role as an advocate and a resource person for the client, who might be eligible for financial assistance and health care coverage during her pregnancy and the postpartum period. Medicaid is a federal and state program that provides health insurance for low-income individuals and families.
Choice A is wrong because contacting the adolescent’s parent for assistance might violate the client’s confidentiality and autonomy, especially if the parent is not aware of or supportive of the pregnancy. The nurse should respect the client’s right to privacy and self-determination unless there is a risk of harm to the client or the fetus.
Choice C is wrong because referring the adolescent to a local mental health clinic might imply that the client has a mental disorder or needs psychological counseling, which could be stigmatizing and discouraging.
The nurse should assess the client’s emotional state and coping skills, and provide supportive and nonjudgmental care. The nurse can also offer referrals to other community resources, such as prenatal education, parenting classes, or social services, that might benefit the client.
Choice D is wrong because advising the adolescent to place the newborn for adoption might interfere with the client’s decision-making process and personal values.
The nurse should not impose his or her own opinions or beliefs on the client but rather explore the client’s feelings and preferences about her pregnancy options. The nurse should provide factual information and education about adoption, abortion, or parenting, and help the client weigh the benefits and risks of each option.
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