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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Weight loss: Weight loss is not a typical manifestation of nicotine withdrawal. While some individuals may experience changes in appetite, particularly an increase in appetite leading to weight gain, weight loss is not a common symptom associated with quitting smoking.
B) Diaphoresis: Diaphoresis, or excessive sweating, is not typically associated with nicotine withdrawal. While some individuals may experience mild symptoms like irritability or nervousness, sweating is not a prominent feature of withdrawal from nicotine.
C) Diarrhea: Diarrhea is not a characteristic symptom of nicotine withdrawal. Some gastrointestinal disturbances such as constipation or changes in appetite may occur, but diarrhea is not a common withdrawal symptom.
D) Insomnia: Insomnia is a well-documented symptom of nicotine withdrawal. Nicotine has stimulating properties, and when an individual stops using nicotine, they may experience difficulty sleeping. This can lead to trouble falling or staying asleep and is a common part of the withdrawal process.
Correct Answer is A
Explanation
A) Ensuring that creases in the stockings on the front of the client's legs:
This action requires intervention. The stockings should be applied smoothly and without any wrinkles or creases, as these can cause pressure points that may lead to skin irritation, impaired circulation, or discomfort for the client. The nurse should ensure that the assistive personnel applies the stockings correctly and without any creases to prevent these issues.
B) Applying the stockings before the client gets out of bed:
This is an appropriate action. Antiembolic stockings should be applied while the client is in a resting position, preferably before getting out of bed, to prevent venous stasis and improve circulation. Applying them while the client is lying down allows for proper fitting and ensures the stockings are worn during periods of immobility.
C) Asking the client to point their toes before applying the stockings:
This is an acceptable action. Asking the client to point their toes helps to stretch and align the legs for proper stocking application, making it easier to apply the stockings without causing discomfort. It is a good practice to ensure the stockings are applied properly while the client's feet and legs are positioned correctly.
D) Turning the stockings inside out before applying them:
This is a correct action. Turning the stockings inside out can help to prevent the stockings from rolling or bunching during application. It also allows the assistive personnel to place them on the client more easily and ensures a proper fit. The stockings should be turned right-side out after being applied to the legs.
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