A nurse is attending to an antepartum client whose lab results show a negative rubella titer.
What is the correct interpretation of this data?
The client is immune to the rubella virus.
The client needs a rubella vaccination immediately.
The client should receive a rubella immunization post-delivery.
The client is not currently infected with the rubella virus.
The Correct Answer is C
Choice A rationale
A negative rubella titer indicates that the client does not have immunity to the rubella virus. Therefore, the statement that the client is immune to the rubella virus is incorrect.
Choice B rationale
While it is true that a person with a negative rubella titer needs a rubella vaccination, it is not recommended to administer the vaccine immediately during pregnancy due to the potential risks to the fetus. Therefore, this statement is not correct in this context.
Choice C rationale
The correct interpretation of a negative rubella titer in an antepartum client is that the client should receive a rubella immunization post-delivery. This is because rubella can cause serious complications if contracted during pregnancy, including congenital rubella syndrome in the newborn. Vaccination post-delivery will protect the client in future pregnancies.
Choice D rationale
A negative rubella titer does not provide information about whether the client is currently infected with the rubella virus. It only indicates that the client does not have immunity to the virus. Therefore, this statement is not a correct interpretation of the data.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D
Choice A rationale: Lanugo, very fine hairs, begin to cover the baby's body around week 20, not week 36. These hairs help protect the skin and usually disappear before birth. By week 36, the lanugo has mostly disappeared, and the baby is almost fully developed.
Choice B rationale: The sex of the baby is determined at conception based on the chromosomes carried by the sperm and egg. However, the external genitalia do not become distinguishable until around week 12 of pregnancy, making week 8 too early for sex determination.
Choice C rationale: Most women first feel fetal movements, known as quickening, between weeks 18 and 22, not week 24. This can vary based on individual factors, but week 24 is generally later than the typical range for first fetal movements.
Choice D rationale: The baby's heartbeat can usually be heard using a Doppler stethoscope by around 12 weeks of pregnancy. This marks a significant milestone and reassures expectant parents about their baby's health and development at this early stage
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale: Inserting an IV catheter is important for potential fluid and medication administration, but it is not the immediate priority action.
Choice B rationale: Administering glucocorticoids is important for fetal lung maturity in case of preterm birth, but it is not the immediate priority upon admission.
Choice C rationale: Applying an external fetal monitor is the priority action. It allows for continuous monitoring of the fetal heart rate and uterine activity to assess the well-being of the fetus and detect any signs of distress.
Choice D rationale: Monitoring vaginal bleeding is important for managing placenta previa, but it is not the immediate priority. Continuous fetal monitoring takes precedence to ensure fetal safety.
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