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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

The correct answer is choice A. The newborn’s nostrils flare slightly during respiration.This is a sign of respiratory distress in a newborn.

Flaring nostrils indicate that the newborn is working hard to breathe and may not be getting enough oxygen.

Choice B is wrong because the newborn’s hands and feet are blue and feel cool.This is a normal finding called acrocyanosis, which occurs due to immature peripheral circulation.

It usually resolves within 24 to 48 hours after birth.

Choice C is wrong because the newborn’s eyes move randomly when his head is turned to the side.This is a normal finding called nystagmus, which occurs due to immature eye muscles and coordination.

It usually disappears by 6 months of age.

Choice D is wrong because the newborn’s tongue thrusts forward when it is lightly touched.This is a normal finding called the extrusion reflex, which helps the newborn to suck and swallow.

It usually fades by 4 months of age.

A. “Have you had any shortness of breath?”. B. “Have you had any episodes of loss of consciousness?”. C. “Have you had any spotting?”. D. “Have you noticed any tenderness in your breasts?”.

Correct Answer is D

Explanation

The correct answer is choice D. “Have you noticed any tenderness in your breasts?”

Breast tenderness is one of the early signs of pregnancy that may occur as early as one to two weeks after conception.It is caused by hormonal changes that prepare the breasts for lactation.

Choice A is wrong because shortness of breath is not a sign of early pregnancy.It may occur later in pregnancy due to the growing uterus pressing on the diaphragm.

Choice B is wrong because episodes of loss of consciousness are not a sign of early pregnancy.They may indicate a serious condition such as anemia, dehydration, or hypoglycemia that requires medical attention.

Choice C is wrong because spotting is not a sign of early pregnancy.

It may be a sign of implantation bleeding, which occurs when the fertilized egg attaches to the lining of the uterus.However, implantation bleeding is usually much lighter and shorter than a normal period.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse is assessing a newborn. Which finding may indicate a problem?

Correct Answer is A

Explanation

A nurse is caring for a female client who suspects she is pregnant. Which question, if asked by the nurse, is consistent with signs of early pregnancy?

Correct Answer is D

Explanation

A client is at the antepartal clinic for a pregnancy test.Which finding, if present, would be considered a positive sign of pregnancy?

A patient who is 26 weeks pregnant has gestational diabetes and is to begin insulin management. When discussing the patient’s insulin needs, which information should the nurse include?

A patient’s labor is induced using an intravenous infusion of 1,000 mL Ringer’s lactate with 10 units of oxytocin. Two hours later, the nurse notes a pattern of late fetal heart rate decelerations detected on the fetal monitor.Which action is essential for the nurse to take first?

he nurse instructs a woman who is attending the infertility clinic about strategies designed to facilitate conception. Which statement by the patient would indicate that she understands the instructions?

A patient states, “My water just broke.” The nurse verifies that her membranes have ruptured spontaneously. Which action should the nurse take next?

A 38-year-old primigravida returns to the clinic at 16 weeks gestation for an alpha-fetoprotein test.She asks a nurse, "Why do lI need this test?".Which response would be most appropriate for the nurse to make?

The nurse is assigned to care for the postpartum client during her shift. The nurse knows one of the most common risk factors for early (PPH) postpartum hemorrhage is uterine atony. When providing care, the nurse would plan to:.