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
he correct answer is choice D. Keep the infant well hydrated.This is because phototherapy can cause dehydration due to increased insensible water loss from the skin.Hydration helps the infant excrete bilirubin in urine and stool.
Choice A is wrong because elevating the head of the infant’s crib does not affect bilirubin levels or phototherapy effectiveness.
Choice B is wrong because applying a water-soluble ointment to the infant’s eyes can interfere with eye protection and cause eye irritation.The infant’s eyes should be covered with opaque patches or goggles during phototherapy to prevent eye damage.
Choice C is wrong because dressing the infant in a long-sleeved shirt reduces the amount of skin exposed to light and decreases the efficacy of phototherapy.The infant should be undressed except for a diaper and eye protection during phototherapy.
Normal ranges for bilirubin levels vary depending on the age of the infant, the type of jaundice, and the method of measurement.Generally, bilirubin levels above 25 mg/dL are considered dangerous and require urgent treatment.
Correct Answer is A
No explanation
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