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 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.
Correct Answer is D
Explanation
The correct answer is choice D. Insufficient relaxation of the uterus between contractions.This is also known astachysystoleorhyperstimulation, which can cause fetal distress and uterine rupture.Oxytocin is a hormone that stimulates uterine contractions, but it can also cause them to be too strong or too frequent if given in high doses or for too long.
Choice A is wrong because oxytocin does not decrease body temperature.
Choice B is wrong because oxytocin does not cause maternal cardiac arrhythmias.
Choice C is wrong because oxytocin does not cause urinary retention.
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