A nurse suspects that a three-year-old child may have rubella based on presenting symptoms. Which of the following questions asked by the nurse (directed at the parents) will be most effective in determining how the child was exposed to the virus?
Whom has the child come into contact with over the last three weeks?
Are your child's immunizations up to date?
What medications have you given your child?
When did you first notice the rash?
The Correct Answer is A
Choice A reason: This statement is correct, as asking about the child's contacts over the last three weeks can help the nurse identify the possible source of infection and the risk of transmission. Rubella is a viral infection that spreads through respiratory droplets or direct contact with an infected person. The incubation period of rubella is 14 to 21 days, meaning that the child could have been exposed to the virus up to three weeks before developing symptoms.
Choice B reason: This statement is incorrect, as asking about the child's immunizations is not the most effective way to determine how the child was exposed to the virus. Although immunization can prevent rubella infection, it is not 100% effective, and some children may still get the disease despite being vaccinated. The nurse should also consider other factors, such as the child's medical history, travel history, and exposure to other people with rash or fever.
Choice C reason: This statement is incorrect, as asking about the medications given to the child is not the most effective way to determine how the child was exposed to the virus. Medications can help relieve the symptoms of rubella, such as fever, rash, or joint pain, but they do not affect the transmission or the course of the infection. The nurse should focus on the epidemiological aspects of the disease, such as the mode of transmission, the incubation period, and the contagious period.
Choice D reason: This statement is incorrect, as asking about the onset of the rash is not the most effective way to determine how the child was exposed to the virus. The rash of rubella usually appears 14 to 17 days after exposure, and lasts for about three days. However, the child can be contagious from seven days before to seven days after the rash appears, meaning that the child could have been exposed to the virus up to four weeks before or after the rash. The nurse should ask about the child's contacts during this period, not just the rash.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is incorrect because breastmilk does contain some iron, although not as much as formula. However, the iron in breastmilk is more bioavailable and easily absorbed by the infant. Therefore, iron drops are not necessary for exclusively breast-fed infants until they are 4 to 6 months old.
Choice B reason: This is incorrect because the iron levels of breast-fed infants will start to decline after 4 to 6 months of age, as their iron stores from the mother are used up. Therefore, they will need iron supplementation from other sources, such as iron-fortified cereals or drops.
Choice C reason: This is correct because the iron stores of breast-fed infants are sufficient for the first 4 to 6 months of life, but then they will need additional iron from other sources. Iron supplementation can prevent or treat iron deficiency anemia, which can affect the infant's growth and development.
Choice D reason: This is incorrect because solids are not recommended for infants younger than 4 months of age, as their digestive system is not mature enough to handle them. Solids can also interfere with the intake of breastmilk, which is the main source of nutrition for infants. Iron-rich foods can be introduced after 6 months of age, along with continued breast-feeding.
Correct Answer is D
Explanation
Choice A reason: This is incorrect because the symptoms described by the mother are not typical of a formula allergy. A formula allergy would cause symptoms such as rash, hives, wheezing, or vomiting within minutes or hours of feeding. Switching to a soy based formula is not recommended without consulting a doctor, as some infants may also be allergic to soy.
Choice B reason: This is incorrect because feeding the infant after vomiting and diarrhea may worsen the condition and cause more dehydration. The infant should be given small amounts of oral rehydration solution (ORS) or breastmilk to prevent fluid loss. If the infant cannot tolerate oral fluids or shows signs of severe dehydration, such as sunken eyes, dry mouth, or lethargy, they should be taken to the emergency department for intravenous rehydration.
Choice C reason: This is incorrect because blood and mucous in the stool are not normal findings in infants and should be investigated promptly. They may indicate a serious condition such as intussusception, which is a telescoping of the bowel that causes obstruction and inflammation. The stool may look like currant jelly due to the presence of blood and mucous. Intussusception is a medical emergency that requires immediate treatment.
Choice D reason: This is correct because the infant's symptoms may indicate a serious condition such as intussusception, which can be life-threatening if left untreated. The infant should be taken to the emergency room for further evaluation and management. The nurse should also advise the mother to monitor the infant's vital signs, hydration status, and urine output until they reach the hospital.
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