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) Assists the client to the bathroom every 2 hr: This action is appropriate as regular assistance with toileting can help prevent falls by ensuring the client is not trying to get up unassisted when they need to use the bathroom. Assisting every 2 hours is reasonable to minimize the risk of falls, especially in clients who are at risk.

B) Clears furniture from the path leading to the bathroom: This action is correct as it reduces environmental hazards that could contribute to a fall. Ensuring that the path to the bathroom is free from obstacles is a key safety measure for clients at risk for falls.

C) Raises all four side-rails on the client's bed: This is an action the nurse should intervene on. Raising all four side rails is considered a restraint in many settings and could increase the risk of injury if the client tries to climb over or becomes entangled. It can also contribute to a feeling of entrapment or confusion. Side rails should only be used according to specific protocols and when necessary for safety, not as a blanket solution for fall prevention.

D) Locks the wheels on the client's bed: Locking the wheels on the bed is an appropriate safety measure. Ensuring the bed is stationary when the client is in it reduces the risk of accidental movement and potential falls.

Correct Answer is []

Explanation

The client reports joint pain in the knee and wrist with a history of gout in the family. The elevated uric acid level (7.2 mg/dL) supports a diagnosis of gout, a condition caused by uric acid crystal deposition in the joints. The negative ANA and normal ESR make inflammatory autoimmune conditions like rheumatoid arthritis and systemic lupus erythematosus unlikely.

Actions to Take:

Instruct the client to avoid foods high in purines.

Purine-rich foods (e.g., red meat, shellfish, organ meats) contribute to increased uric acid production, exacerbating gout symptoms. Dietary modifications can help reduce flare-ups and long-term complications.

Instruct the client to apply topical analgesics.

Topical analgesics can provide localized pain relief and reduce discomfort in affected joints. They serve as an adjunct to systemic medications in managing acute symptoms.

Parameters to Monitor:

Uric acid levels.

Monitoring uric acid levels helps assess the effectiveness of dietary changes and medications in preventing flare-ups and reducing joint damage.

Joint deformities.

Chronic gout can lead to joint destruction and tophi formation, so assessing for deformities helps track disease progression and the need for further interventions.

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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 supervising an assistive personnel (AP) who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?

Correct Answer is C

Explanation

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Correct Answer is []

Explanation

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