Nokea
A nurse is assessing a newborn whose mother had a primary cytomegalovirus (CMV) infection during pregnancy. The newborn acquired CMV transplacentally. Which of the following findings should the nurse expect the newborn to exhibit?
- A. Urinary tract infection
- B. Hearing loss
- C. Macrosomia
- D. Cataracts
Correct Answer: B
Rationale: The correct answer is B: Hearing loss. CMV infection during pregnancy can lead to congenital CMV in newborns, resulting in various complications. Hearing loss is a common manifestation of congenital CMV infection. The virus can damage the inner ear structures, leading to sensorineural hearing loss. This complication is crucial to monitor and address early to prevent long-term consequences.
Incorrect choices:
A: Urinary tract infection - Not typically associated with congenital CMV infection.
C: Macrosomia - Excessive birth weight, not a common manifestation of congenital CMV infection.
D: Cataracts - Uncommon in congenital CMV infection; typically associated with other congenital infections like rubella.
You may also like to solve these questions
The nurse is teaching a client and her partner about the technique of counter pressure during labor. Which of the following statements by the nurse is appropriate?
- A. Your partner will apply upward pressure on your lower abdomen between contractions
- B. Your partner will apply continuous firm pressure between your thumb and index finger
- C. Your partner will apply pressure to the top of your uterus during contractions
- D. Your partner will apply steady pressure with a tennis ball to your lower back
Correct Answer: D
Rationale: The correct answer is D because counter pressure is typically applied to the lower back to help alleviate back pain during labor contractions. This technique can help relieve discomfort by stimulating pressure receptors and distracting from the pain of contractions. Choice A is incorrect as upward pressure on the lower abdomen is not the standard technique for counter pressure. Choice B is incorrect as applying pressure between the thumb and index finger is not relevant to counter pressure. Choice C is incorrect as pressure should be applied to the lower back, not the top of the uterus, during contractions.
A nurse is assisting with an amniotomy on a client who is in labor. Which of the following situations should the nurse take?
- A. Place the client in the left lateral position
- B. Ensure that the fetal head is engaged
- C. Give the provider clean gloves during the procedure
- D. Check the clients temperature every 4 hours after the procedure
Correct Answer: B
Rationale: The correct answer is B: Ensure that the fetal head is engaged. This is crucial before performing an amniotomy to prevent umbilical cord prolapse. If the fetal head is not engaged, there is a risk of cord compression. Placing the client in the left lateral position (choice A) is not directly related to the amniotomy procedure. Giving the provider clean gloves (choice C) is important for infection control but not specifically related to ensuring fetal head engagement. Checking the client's temperature (choice D) is important for monitoring but not a priority before an amniotomy.
A nurse on postpartum unit caring for four clients. Which of the following clients should receive Rh, (D) Immune globulin to prevent Rh- is immunization?
- A. An Rh-negative mother who has an Rh- positive infant
- B. An Rh –positive mother who has an Rh- negative infant
- C. An Rh-positive mother who has an Rh- positive infant
- D. An Rh- negative mother who has an Rh- negative infant
Correct Answer: A
Rationale: The correct answer is A: An Rh-negative mother who has an Rh-positive infant. This mother is at risk for developing Rh isoimmunization, a condition where her immune system attacks the Rh-positive red blood cells of her infant, potentially causing harm in future pregnancies. Rh(D) Immune globulin is given to prevent this by blocking the mother's immune response to the Rh-positive cells of the infant. The other choices do not require Rh(D) Immune globulin because they do not involve the risk of Rh isoimmunization. Choice B involves an Rh-positive mother who is not at risk of isoimmunization. Choice C involves an Rh-positive mother with an Rh-positive infant, so there is no incompatibility. Choice D involves an Rh-negative mother with an Rh-negative infant, so there is no risk of isoimmunization.
A nurse is caring for a client who is 36 weeks gestation and has MRSA. Which of the following isolation precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Airborne
- D. Protective environment
Correct Answer: B
Rationale: The correct answer is B: Contact isolation. This is because MRSA is primarily spread through direct physical contact with the infected individual or contaminated surfaces. By implementing contact precautions, the nurse can prevent the spread of MRSA to other patients and healthcare workers. Droplet precautions (choice A) are used for diseases spread through large respiratory droplets, such as influenza. Airborne precautions (choice C) are for diseases transmitted through small respiratory droplets that remain suspended in the air, like tuberculosis. Protective environment (choice D) is used for immunocompromised patients to protect them from environmental pathogens. Therefore, the most appropriate precaution for a client with MRSA at 36 weeks gestation is contact isolation.
A nurse is planning to teach a group of clients who are about breastfeeding after returning to work. Which of the following infection should the nurse include in the teaching?
- A. “Thawed breast milk can be refrigerated for up to 72 hours.”
- B. “Breast milk can be stored in a deep freezer for 12 months.”
- C. Breast milk can be stored at room temperature for up to 12 hours.”
- D. “Thawed breast milk that is unused can be refrozen.”
Correct Answer: B
Rationale: The correct answer is B: “Breast milk can be stored in a deep freezer for 12 months.” This is correct because breast milk can indeed be stored in a deep freezer for up to 12 months, maintaining its quality and safety. Deep freezing helps preserve the nutrients in breast milk for a longer period compared to standard refrigeration.
Choice A is incorrect because thawed breast milk should be used within 24 hours if stored in the refrigerator, not 72 hours. Choice C is incorrect because breast milk can only be stored at room temperature for up to 4 hours. Choice D is incorrect because thawed breast milk should not be refrozen; it should be used within 24 hours.