A 14-year-old client who is pregnant has a low result from a rubella serology test.Which notation should be made on this client’s care plan?

Rubella immunization should be given in the early postpartum period.

Gamma globulin should be given when the client is admitted in labor.

Gamma globulin should be given at next visit.

Rubella immunization should be given at next visit.

Answer and Explanation

The Correct Answer is A

Rubella immunization should be given in the early postpartum period. This is because rubella infection during pregnancy can cause serious birth defects or miscarriage, and rubella vaccine is contraindicated during pregnancy. Therefore, the best time to vaccinate a woman who is not immune to rubella is after she delivers her baby.

Choice B is wrong because gamma globulin is not effective for preventing rubella infection or congenital rubella syndrome (CRS). Gamma globulin is a preparation of antibodies that can provide temporary protection against some infections, but it does not induce lasting immunity.

Choice C is wrong because gamma globulin should not be given at the next visit for the same reason as choice B. Moreover, gamma globulin can interfere with the response to live vaccines such as rubella vaccine, so it should not be given within 3 months before or after vaccination.

Choice D is wrong because rubella immunization should not be given at the next visit or during pregnancy, as it can pose a risk to the fetus. Rubella vaccine is a live attenuated virus vaccine that can cross the placenta and infect the fetus. The risk of CRS from vaccination during pregnancy is low, but it cannot be ruled out completely. Therefore, women who receive rubella vaccine should avoid pregnancy for at least 4 weeks after vaccination.

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Correct Answer is D

Explanation

The correct answer is choice D. Presence of human chorionic gonadotropin (hCG) in blood.This is apositive sign of pregnancythat can only be attributed to a fetus.hCG is a hormone produced by the placenta that can be detected in blood or urine tests.

Choice A. Quickening.This is apresumptive sign of pregnancythat is based on the woman’s report of feeling fetal movements in her lower abdomen.This can occur at 16 weeks for second time moms and around 20 weeks for first time moms.However, this sign is not conclusive as other conditions can cause similar sensations.

Choice B. Uterine enlargement.This is aprobable sign of pregnancythat can be observed by the nurse or doctor through palpation.However, this sign does not mean 100% that a baby is growing in the uterus as it can be due to other causes such as fibroids or tumors.

Choice C. Urinary frequency.This is apresumptive sign of pregnancythat is based on the woman’s report of needing to urinate more often than usual.This can be caused by hormonal changes and increased blood volume during pregnancy.However, this sign is not definitive as other conditions such as urinary tract infections or diabetes can also cause frequent urination.

A. “I’m planning to have an IUD inserted when I go for my six-week checkup.”. B. “Having an IUD in place may cause my periods to be heavier.”. C. “I will not be able to use an IUD as a birth control method if I have more than three full-term pregnancies.”. D. “The IUD works by causing an inflammatory response in my uterus, and that discourages a fertilized egg from becoming implanted.”.

Correct Answer is C

Explanation

The correct answer is choice C.Choice C is wrong because having more than three full-term pregnancies does not affect the suitability of using a copper IUD as a birth control method.Copper IUDs are long-term, reversible contraceptives that can be used by premenopausal women of all ages, including those who have never been pregnant or who have had multiple pregnancies.

Choice A is correct because a copper IUD can be inserted anytime during a normal menstrual cycle, or up to eight weeks after childbirth.

Choice B is correct because a copper IUD may cause heavier and longer periods, as well as more cramping.

Choice D is correct because a copper IUD works by creating an inflammatory response in the uterus that prevents sperm from reaching the egg and fertilizing it, and also prevents a fertilized egg from implanting in the uterine wall.

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A 14-year-old client who is pregnant has a low result from a rubella serology test.Which notation should be made on this client’s care plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A nurse is providing information to a patient regarding contraception methods. Which statement by the patient indicates a need for further teaching regarding use of copper intrauterine device (IUD)?

Correct Answer is C

Explanation

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