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 D

Explanation

The correct answer is choice D. Decreased respirations.Magnesium sulfate is a medication that can causerespiratory depression, which means it can slow down or stop breathing.

This is a serious side effect that needs to be monitored closely by the nurse.

Choice A is wrong because increased Babinski reflex is not a side effect of magnesium sulfate.

The Babinski reflex is a normal response in infants, but abnormal in adults.

It occurs when the big toe bends upward and the other toes fan out when the sole of the foot is stroked.Magnesium sulfate can causepoor reflexes, but not specifically the Babinski reflex.

Choice B is wrong because diarrhea is not a side effect of magnesium sulfate when given intravenously or intramuscularly.Diarrhea can occur when magnesium sulfate is taken orally as a laxative, but that is not the case in this question.

Choice C is wrong because tetany is not a side effect of magnesium sulfate.

Tetany is a condition that causes muscle spasms and cramps due to low levels of calcium in the blood.Magnesium sulfate can actually causehypocalcemia, which means low levels of calcium in the blood, but this does not usually result in tetany.Tetany is more likely to occur when there is low magnesium in the blood, which is calledhypomagnesemia.

A. “Would you like to take a break for a while?”. B. “You are doing a great job. C. It’s very difficult to support someone during this part of labor.”. D. “Perhaps she’ll respond better to someone else. E. Can you call someone to help?”.

Correct Answer is B

Explanation

The correct answer is choice B. “You are doing a great job.

It’s very difficult to support someone during this part of labor.” This response acknowledges the husband’s feelings and efforts, and provides reassurance and encouragement.

It also reflects the reality that active labor can be very intense and painful for the woman, and she may not want to be touched or talked to.

Choice A is wrong because it suggests that the husband is not needed or wanted, and may make him feel rejected or useless.

Choice C is wrong because it implies that the husband is not a good support person, and may hurt his self-esteem or damage his relationship with his wife.

Choice D is wrong because it focuses on the physical aspect of labor, rather than the emotional one.

It also assumes that the woman wants medication, which may not be the case.

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 patient is receiving magnesium sulfate.Which side effect should the nurse monitor for with this patient?

Correct Answer is D

Explanation

nurse hears a client in active labor say to her husband, “Don’t touch me. Stay away.” The husband states, “I don’t know what to do. Everything I do is wrong.” Which response by the nurse would be the most supportive?

Correct Answer is B

Explanation

A patient who is 33 weeks pregnant has been experiencing Braxton-Hicks contractions.Which information should the nurse include in responding to this patient?

A mother of a 3-hour-old infant requests information concerning breastfeeding. The mother has tested positive for human immunodeficiency virus (HIV).A nurse’s response should be based on which fact?

A 23-year-old primigravida who appears to be in her third trimester of pregnancy comes to the labor and delivery unit reporting acute abdominal pain. She has had no prenatal care. Which assessment should the nurse do first?

A patient has been instructed to increase the protein in her diet. Which statement by the patient shows a need for further instruction?

A patient had a cesarean delivery due to placenta previa.Which statement by the patient would indicate that she understands why she had the cesarean delivery?

A client who is twO weeks postpartum calls the office and tells a nurse, "l am havinga small amount of brownish discharge from my vagina." Which response is appropriate for the nurse to make?

A patient who is 34 weeks pregnant attends the antepartal clinic and is diagnosed with mild pregnancy-induced hypertension (PIH). The decision is made to treat the patient at home. Which instruction would be most appropriate to give to the patient?

When assessing a newborn, which is the best method for the nurse to use to elicit the Moro reflex?