A client’s prenatal laboratory findings reveal no immunity to rubella.
The health care provider orders the rubella vaccine.
The nurse concludes that teaching about this medication is effective when the client states which of the following?
“I should not get pregnant for at least 4-12 weeks after the vaccine.”.
“I need another shot after each baby I have with Rh-positive blood.”.
“I need another shot in 1 month and again in 6 months.”.
“This shot may cause a fever and make me vomit.”.
The Correct Answer is A
Choice A rationale
The rubella vaccine is a live vaccine, which means it contains a weakened version of the virus. Because the virus is still active, live vaccines are not safe for pregnant people. There is a small chance they may pass the virus to the baby. Therefore, it is recommended that adults of childbearing age should avoid getting pregnant for at least four weeks after receiving the MMR vaccine. This is to ensure the safety of both the mother and the baby.
Choice B rationale
This statement is incorrect. The rubella vaccine does not require additional shots after each baby with Rh-positive blood. The rubella vaccine is typically administered in childhood and provides long-term protection.
Choice C rationale
This statement is also incorrect. The rubella vaccine does not require additional shots in 1 month and again in 6 months. The vaccine provides long-term protection and does not typically require frequent boosters.
Choice D rationale
While it’s true that some vaccines can cause side effects such as fever and vomiting, these are not common side effects of the rubella vaccine. Therefore, this statement is not entirely accurate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While followers demonstrating high critical thinking are valuable, passive contribution may not be as beneficial to a nurse leader’s performance. Active participation is often more beneficial in a healthcare setting, as it allows for the exchange of ideas and collaborative problem-solving.
Choice B rationale
Followers who are dependent and passive when they disagree may not contribute effectively to the team’s performance. Constructive disagreement can lead to better decision-making and innovation. Therefore, passive disagreement may not be the most beneficial trait for a nurse leader.
Choice C rationale
Followers who are active contributors and participate in developing and analyzing ideas are highly beneficial to a nurse leader’s performance. Active participation fosters a collaborative environment, encourages the exchange of ideas, and leads to innovative solutions. This type of follower can significantly enhance the performance of a nurse leader and the overall team.
Choice D rationale
While participation in developing and analyzing ideas is important, not being an active contributor can limit the effectiveness of this participation. Active contribution is key to fostering a collaborative and innovative environment.
Correct Answer is C
Explanation
Choice A rationale
Explaining the procedure for an upper gastrointestinal series is important for a client diagnosed with gastrointestinal bleeding. However, it is not the first action a nurse should take. The nurse’s initial focus should be on assessing the client’s condition and stabilizing vital signs.
Choice B rationale
Administering pain medication is important for a client’s comfort, but it is not the first action a nurse should take. The nurse’s initial focus should be on assessing the client’s condition and stabilizing vital signs.
Choice C rationale
Assessing orthostatic blood pressure is the first action a nurse should take when caring for a client diagnosed with gastrointestinal bleeding. Orthostatic hypotension (a drop in blood pressure when standing up from a sitting or lying position) can be a sign of significant blood loss. This assessment helps determine the severity of the bleeding and guides further interventions.
Choice D rationale
Testing the client’s emesis for blood is an important part of diagnosing and managing gastrointestinal bleeding. However, it is not the first action a nurse should take. The nurse’s initial focus should be on assessing the client’s condition and stabilizing vital signs.
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