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 A

Explanation

The correct answer is choice C. Caloric intake should be 300 calories above the suggested non-pregnant caloric intake.This is because women with gestational diabetes need to meet the nutritional needs of pregnancy and also control their blood glucose levels.

Choice A is wrong because carbohydrates should make up about 45% of the total dietary intake for women with gestational diabetes, not 25%.

Carbohydrates are important for providing energy and nutrients for the mother and the baby.

Choice B is wrong because animal protein can be included in the pre-bedtime snack as long as it is combined with some carbohydrates.

Protein can help prevent low blood glucose levels during the night.

Choice D is wrong because sugar substitutes do not help to control blood glucose levels.They may also have adverse effects on the baby’s development.Women with gestational diabetes should limit their intake of added sugars and choose foods with natural sugars instead.

A. “You don’t need to breastfeed now if you would rather wait for your milk to come in.”. B. “It is good practice for you to breastfeed now so that you will be skilled when your milk comes in.”. C. “The earlier you begin to breastfeed your baby, the closer you and your baby may become.”. D. “The fluid you have in your breasts now is just what the baby needs.”.

Correct Answer is D

Explanation

The correct answer is choice D. The fluid that the mother has in her breasts before the milk comes in is called colostrum, which is rich in antibodies and nutrients that the baby needs.

It also helps to prevent jaundice by stimulating the baby’s bowel movements.

Therefore, the nurse should encourage the mother to breastfeed as soon as possible after birth and explain the benefits of colostrum.

Choice A is wrong because it discourages breastfeeding and may interfere with milk production and bonding.

Choice B is wrong because it implies that breastfeeding is only a skill and not a natural process that benefits both the mother and the baby.

Choice C is wrong because it focuses on the emotional aspect of breastfeeding and not the physiological one.

While breastfeeding may enhance the closeness between the mother and the baby, it is not the only reason to breastfeed.

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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

A nurse is caring for a client with gestational diabetes.Which guideline should the nurse use when providing nutritional counseling to this client?

Correct Answer is A

Explanation

During the first postpartum day, a new mother is breastfeeding her infant.The client asks, “Since I don’t have any milk yet, why am I breastfeeding?” Which response by the nurse is most appropriate?

Correct Answer is D

Explanation

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?

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