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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Dry off the newborn.This is the priority nursing action because it prevents heat loss and hypothermia in the newborn.
The newborn has a large surface area and a thin layer of subcutaneous fat, making it vulnerable to cold stress.Drying off the newborn also stimulates breathing and crying, which helps clear the airways.
Choice A is wrong because obtaining a serum sample is not a priority action and may cause unnecessary pain and bleeding in the newborn.
Choice C is wrong because assessing the newborn’s Moro reflex is not a priority action and may be done later during the physical examination.Choice D is wrong because obtaining the newborn’s footprints is not a priority action and may be done after the bonding and breastfeeding period.
Correct Answer is B
Explanation
The correct answer is choice B. Apply ice to her perineal area.This is because ice can help reduce swelling and pain in the episiotomy wound, which is a cut made in the tissue between the vagina and anus during childbirth.Ice should be applied for the first 24 to 48 hours after delivery.
Choice A is wrong because Kegel exercises, which involve contracting and relaxing the pelvic floor muscles, are not recommended for the first 12 hours after an episiotomy.They can increase blood flow and inflammation in the area, and may interfere with healing.
Choice C is wrong because keeping her hips slightly elevated can cause pressure on the episiotomy wound and increase discomfort.It can also affect blood circulation and drainage in the area.
Choice D is wrong because observing her perineal area for signs of infection is not a nursing action that should be included in her plan of care for the first 12 hours.Infection is rare in episiotomy wounds, and signs of infection usually appear after 24 hours or later.However, the nurse should teach the patient how to keep the area clean and dry, and when to report any signs of infection, such as fever, pus, or foul-smelling discharge.
Normal ranges for episiotomy healing are:
• Stitches dissolve within 2 to 4 weeks
• Pain and swelling subside within a few days to a week
• Wound heals completely within 4 to 6 weeks
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