A nurse is assisting with the care of a client on their first prenatal visit. Which of the following screenings require follow up intervention?

Rubella titer nonimmune

Negative varicella titer

Positive Rh factor

Positive serologic test for syphilis

Answer and Explanation

The Correct Answer is D

A) Rubella titer nonimmune: A nonimmune rubella titer indicates that the client is not immune to rubella, which is a common finding in many pregnant women. However, rubella vaccination is not given during pregnancy because the vaccine is a live virus. The client will typically be vaccinated postpartum. Follow-up would be required, but it is not an urgent concern during the pregnancy itself.

B) Negative varicella titer: A negative varicella titer means the client is not immune to chickenpox, which is a concern because varicella can cause serious complications during pregnancy. However, similar to rubella, the varicella vaccine is contraindicated during pregnancy, and vaccination would be given postpartum. This requires follow-up after delivery but does not require urgent intervention during the pregnancy.

C) Positive Rh factor: The Rh factor is a blood type characteristic, but what is typically more concerning is the Rh incompatibility, which occurs when a Rh-negative mother carries a Rh-positive baby. A positive Rh factor is not a problem for the client themselves but could be important if the father is Rh-positive. If there is concern for Rh incompatibility, the nurse would monitor for the development of Rh sensitization and administer Rh immunoglobulin (RhoGAM) if needed. This does not require urgent intervention unless Rh incompatibility is confirmed.

D) Positive serologic test for syphilis: A positive test for syphilis requires immediate follow-up intervention. Syphilis is a sexually transmitted infection that can cause serious complications during pregnancy, including miscarriage, stillbirth, preterm birth, and congenital syphilis. Treatment with penicillin is recommended to prevent transmission to the baby and to treat the infection in the mother. A positive serologic test for syphilis warrants prompt intervention.

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Correct Answer is C

Explanation

A. Facial erythema is not a primary diagnostic feature of this specific respiratory bacterial infection. While intense coughing fits may cause temporary facial flushing or venous congestion, it is not a hallmark finding. Conditions like fifth disease or slapped-cheek syndrome are more likely to present with persistent malar rashes. This sign lacks the specificity required for a pertussis diagnosis.

B. Peeling of the skin on the extremities, known as desquamation, is classically associated with Kawasaki disease or scarlet fever. Bordetella pertussis does not typically produce the exotoxin profile necessary to cause significant integumentary shedding or widespread dermatological involvement. The pathology of pertussis is primarily localized to the ciliated epithelium of the respiratory tract. It is not an exfoliative disease.

C. In the catarrhal phase of the infection, a low-grade temperature is a standard clinical finding as the immune system responds to the initial bacterial colonization. The presence of systemic inflammation results in mild pyrexia alongside coryza. This manifestation is most prominent before the onset of the characteristic paroxysmal cough. Fever helps differentiate early pertussis from non-inflammatory conditions.

D. A beefy, red tongue, often described as a strawberry tongue, is a classic sign of scarlet fever or toxic shock syndrome. This manifestation occurs due to capillary permeability and inflammation of the lingual papillae caused by Streptococcus pyogenes. Pertussis involves the respiratory mucosa rather than the oral structures or the tongue. This symptom indicates a different bacterial or inflammatory etiology.

Correct Answer is ["0.25"]

Explanation

Identify the desired dose:

The doctor has ordered 0.5 mg of haloperidol.

Identify the available medication concentration:

The available haloperidol oral concentrate is 2 mg/mL.

Set up the calculation:

We need to find out how many mL are needed to administer 0.5 mg of the medication. We can use the following formula:

(Desired dose) / (Concentration) = Volume to administer

Plug in the values and calculate:

(0.5 mg) / (2 mg/mL) = 0.25 mL

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A nurse is assisting with the care of a client on their first prenatal visit. Which of the following screenings require follow up intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?

Correct Answer is C

Explanation

A nurse is preparing to administer haloperidol 0.5 mg by mouth to an older adult client. The amount available is haloperidol oral concentrate 2mg/mL. How many mL should the nurse administer? (Round the answer to the nearest hundredth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.25"]

Explanation

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