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1. Which statement helps the nurse determine that a woman with genital her-
pes (HSV-2) infection understands her self-care?
1). "When I have a baby, I don't want a cesarean."
2). "I can have sex as soon as the herpes sores have healed."
3). "When I finish the acyclovir prescription I will be cured.").
4). "I must be careful when I have sex because herpes is a lifelong problem.": 4).
"I must be careful when I have sex because herpes is a lifelong problem."
HSV-2 infection is characterized by remissions and exacerbations; it cannot be cured and is a lifelong infection. Some
pregnant women with HSV-2 need cesarean deliveries, which are indicated if there is an outbreak of HSV-2 near the
time of birth to prevent their newborns from contracting the disease while passing through the vagina. Herpes is most
contagious when active lesions are present; however, the virus can still be shed after the lesions have healed. Use of a
condom can reduce the risk of transmission. Herpes can be controlled but not cured.
2. Which priority nursing action would the nurse implement for an infant recent-
ly admitted with a diagnosis of diarrhea caused by a Salmonella infection?
1). Monitoring oral fluid intake
2). Establishing a play schedule
3). Obtaining a recent food history
4). Establishing a skin care routine: 4). Establishing a skin care routine
Enzymes in the stool may irritate the skin; maintaining skin integrity is the priority. Fluid intake is important to monitor
for dehydration, though some infants may receive IV fluids. Establishing a play schedule is not the priority of care.
Physiologic problems, such as altered skin integrity, should be addressed first. Although obtaining a food history is
important, it is not the priority.
3. Which nursing action is most effective in controlling the spread of infection
for an infant with diarrhea?
1). Wearing a gown and gloves during care
2). Allowing only registered nurses to give direct care
3). Restricting visitors to the infant's immediate family
4). Washing hands before and after contact with the infant: 4). Washing hands before
, NU271 Week 8 EAQ Evolve Elsevier: Infection
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and after contact with the infant
The most effective method of preventing the spread of infection is hand washing not only before and after care but
also before and after using gloves. A gown and gloves are not required for contact precautions. The level of education
of the caregiver does not guarantee the correct technique for preventing the spread of infection. The risk for spread of
infection is not in the number of visitors but in the aseptic technique practiced by these visitors.
4. Which would the nurse teach the parent of an infant who is at risk for
infections?
1). "You must avoid placing the infant in bright sunlight."
2). "Breast-feeding will provide protection against bacteria."
3). "Use soy-based infant formulas to help prevent infection."
4). "The infant will be less susceptible to infections later in life.": 2). "Breast-feeding
will provide protection against bacteria."
Breast milk contains immunoglobulin G (IgG) that protects the infant against many bacteria, such as Escherichia coli.
The nurse instructs the parent to avoid placing the infant in bright sunlight for a long period of time to prevent burns,
but not to prevent infections. Soy-based infant formulas are used only if the infant is allergic to lactose in the breast
milk and are not used to prevent the risk for infections. Later, susceptibility would be dependent on multiple factors,
including nutrition and exposure to infections.
5. Which type of immunity would a 4-year-old child develop during the course
of an infection with varicella?
1). Active natural immunity
2). Active artificial immunity
3). Passive natural immunity
4). Passive artificial immunity: 1). Active natural immunity
In active natural immunity, the infected child's immune system responds to the invading organism (varicella) by
producing antibodies specific to the antigen. Passive natural immunity is acquired by the fetus from the mother. Active
artificial immunity is acquired by the injection of antigens; after this, the child develops antibodies. Passive artificial
immunity is acquired through the injection of antibodies.