A nurse is caring for a client who has rubella at the time of delivery and asks why her newborn is being placed in isolation. Which of the following responses by the nurse is appropriate?
"The child might develop encephalitis, a complication of rubella."
"Exposure to rubella will suppress the newborn's immune response."
"The newborn is at risk for developing a TORCH infection."
"The newborn might be actively shedding the virus."
The Correct Answer is D
Choice A: While rubella can lead to complications like encephalitis, this answer does not address the reason for isolation precautions for the newborn.
Choice B: While rubella can suppress the immune response in general, it does not explain the need for isolation of the newborn specifically.
Choice C: TORCH (Toxoplasmosis, Rubella, Cytomegalovirus, and Herpes) infections are a group of infections that can be transmitted from mother to fetus during pregnancy. While rubella is part of the TORCH infections, this answer does not specifically address the reason for isolation of the newborn after delivery.
Choice D: Rubella, also known as German measles, is a contagious viral infection. Newborns born to mothers with rubella can be at risk because the virus can be transmitted to them during delivery. The newborn might be actively shedding the virus, which is why isolation precautions are necessary to prevent the spread of the infection to other vulnerable newborns or individuals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
Choice A: Amniocentesis is not primarily performed to determine the gender of the fetus. The main indication for this procedure is to detect genetic abnormalities or chromosomal disorders.
Choice B: The primary purpose of an amniocentesis is to detect chromosomal abnormalities such as Down syndrome (trisomy 21), trisomy 18, and trisomy 13, among others.
Choice C: Rh incompatibility is assessed through blood tests, not amniocentesis. It involves determining the Rh factor of the mother's blood and monitoring for potential Rh sensitization.
Choice D: Cephalopelvic disproportion refers to a situation where the baby's head is too large or the mother's pelvis is too small to allow for a vaginal delivery. It is not related to amniocentesis.
Choice E: While detecting neural tube defects can be done through amniocentesis, it is not the primary indication for the procedure. Neural tube defects can also be screened for through blood tests and ultrasound examinations. Amniocentesis is more commonly used for chromosomal analysis.
Correct Answer is A
Explanation
Choice A: Late decelerations in the fetal heart rate are often associated with uteroplacental insufficiency, and one of the first interventions is to improve uterine blood flow by changing the client's position. Placing the client in a left lateral position can help relieve pressure on the vena cava and improve blood flow to the placenta and the baby.
Choice B: Administering oxygen is a correct intervention for late decelerations, but it should follow the position change. Oxygen administration helps increase oxygen levels in the maternal blood, which can improve fetal oxygenation.
Choice C: Applying a fetal scalp electrode can provide continuous fetal heart rate monitoring, but it does not address the immediate concern of late decelerations. Position change and oxygen administration should be the priority.
Choice D: Increasing the rate of the IV infusion might not have an immediate effect on resolving late decelerations. Position change and oxygen administration should be the initial interventions.
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