A client had a rubella infection (German measles) during the fourth month of pregnancy. At the
time of the infant's birth, the nurse places the newborn in the isolation nursery. What type of
infection control precautions should the nurse institute?
1
Enteric
2
Contact
3
Droplet
4
Standard - A client had a rubella infection (German measles) during the fourth month of
pregnancy. At the time of the infant's birth, the nurse places the newborn in the isolation
nursery. What type of infection control precautions should the nurse institute?
1
Enteric
2
Contact
Correct3
Droplet
Incorrect4
Standard
Because the rubella virus is found in the respiratory tract and urine, isolation is necessary;
rubella is spread by droplets from the respiratory tract. "Enteric precautions" is an outdated
term; the techniques used with this precaution are incorporated under contact precautions, and
the techniques used with contact precautions are incorporated under standard precautions. The
use of standard precautions alone is unsafe; additional precautions must be implemented to
protect the nurse from droplet transmitted infection.
,A client gives birth to a full-term newborn with an 8/9 Apgar score. Place the initial nursing care
actions in order of their priority.
1.
Apply identification band to mother and infant.
2.
Perform physical assessment.
3.
Place skin to skin.
4.
Instill antibiotic prophylaxis and administer vitamin K. - A client gives birth to a full-term
newborn with an 8/9 Apgar score. Place the initial nursing care actions in order of their priority.
Incorrect
1.
Apply identification band to mother and infant.
Incorrect
2.
Perform physical assessment.
Incorrect
3.
Place skin to skin.
Correct
4.
,Instill antibiotic prophylaxis and administer vitamin K.
Hypothermia can cause many complications for a newborn, and therefore it should be avoided
by initiating skin-to-skin contact Placing the identification band on the mother and infant is a
safety measure that should be performed after thermoregulation needs are met. A physical
assessment should be performed next to identify any additional nursing interventions that may
be needed in light of physical assessment findings. Instillation of the antibiotic and
administration of vitamin K should be completed within an hour of birth or per facility policy.
A client who has type O Rh-positive blood gives birth. The neonate has type B Rh-negative
blood. When the nurse assesses the neonate 11 hours after birth, the infant's skin appears
yellow. What is the most likely cause?
1
Neonatal sepsis
2
Rh incompatibility
3
Physiologic jaundice
4
ABO incompatibility - A client who has type O Rh-positive blood gives birth. The neonate has
type B Rh-negative blood. When the nurse assesses the neonate 11 hours after birth, the
infant's skin appears yellow. What is the most likely cause?
1
Neonatal sepsis
2
Rh incompatibility
Incorrect3
Physiologic jaundice
Correct4
ABO incompatibility
, There is an apparent ABO incompatibility because the mother is O and the infant is B;
incompatibility can cause jaundice within the first 24 hours. The information provided does not
indicate neonatal sepsis. Rh incompatibility is not a factor because the mother is Rh positive.
Jaundice in the first 24 hours is not physiologic; it is pathologic.
A mother who is formula feeding her 1-month-old infant asks the nurse whether any vitamin or
mineral supplements are required. The nurse bases the reply on the knowledge that infants
who are fed with ready-to-use formula do require a supplement. What supplement is required?
1
Iron
2
Fluoride
3
Vitamin K
4
Vitamin B12 - A mother who is formula feeding her 1-month-old infant asks the nurse whether
any vitamin or mineral supplements are required. The nurse bases the reply on the knowledge
that infants who are fed with ready-to-use formula do require a supplement. What supplement
is required?
Incorrect1
Iron
Correct2
Fluoride
3
Vitamin K
4
Vitamin B12
Unless fluoridated water is used by the manufacturer, fluoride supplementation of 0.25 mg daily
is required. Commercial formulas are fortified with iron. The supply of vitamin K is adequate