A nurse is caring for a client during the first trimester of pregnancy.
After reviewing the client’s blood work, the nurse notices she does not have immunity to rubella. When should the nurse understand is the recommended time for rubella immunization?

Shortly after giving birth.

During her next attempt to get pregnant.

Immediately in the third trimester.

During the second trimester.

Answer and Explanation

The Correct Answer is A

Choice A rationale

The recommended time for rubella immunization for a woman who does not have immunity is shortly after giving birth. The MMR vaccine, which protects against measles, mumps, and rubella, is a live virus vaccine and is not recommended during pregnancy.

Choice B rationale

While it’s important for a woman to have immunity to rubella before her next pregnancy, waiting until her next attempt to get pregnant to get the vaccine could potentially leave her unprotected if she becomes pregnant sooner than planned.

Choice C rationale

The MMR vaccine is not recommended during pregnancy, including in the third trimester.

Choice D rationale

The MMR vaccine is not recommended during pregnancy, including in the second trimester.

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Correct Answer is B

Explanation

Choice A rationale

Turning the newborn on his side is a good practice to prevent aspiration, but it is not the first action to take. The newborn’s airway must be clear first to ensure proper breathing.

Choice B rationale

Suctioning the mouth with a bulb syringe is the priority action when a newborn has secretions bubbling out of the nose and mouth. This action helps clear the airway and allows the newborn to breathe more easily.

Choice C rationale

Suctioning the nose with a bulb syringe is also important, but the mouth should be suctioned first. This is because the newborn could aspirate oral secretions during inhalation if the mouth is not suctioned first.

Choice D rationale

Using a suction catheter with low negative pressure is not the first action to take. A bulb syringe is usually sufficient to clear the newborn’s airway of secretions.

A. The mother applies lotion to the newborn’s skin. B. The newborn’s eyes are covered with a mask. C. The newborn’s stools increase in number. D. A pink rash appears on the newborn’s trunk.

Correct Answer is A

Explanation

Choice A rationale

Applying lotion to the newborn’s skin during phototherapy is not recommended. Lotion can block the light from reaching the skin and reduce the effectiveness of the treatment.

Choice B rationale

Covering the newborn’s eyes with a mask during phototherapy is a standard practice. This is done to protect the newborn’s eyes from the intense light used in phototherapy.

Choice C rationale

An increase in stool frequency is expected during phototherapy. This is because phototherapy helps to break down bilirubin, which is then excreted in the stool.

Choice D rationale

A pink rash on the newborn’s trunk does not require intervention during phototherapy. It could be a common newborn rash that will resolve on its own.

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A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client’s blood work, the nurse notices she does not have immunity to rubella. When should the nurse understand is the recommended time for rubella immunization?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has just delivered a newborn. The nurse notices secretions bubbling out of the newborn’s nose and mouth. Which of the following actions should the nurse prioritize?

Correct Answer is B

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is caring for an infant who is receiving phototherapy. Which of the following findings requires intervention by the nurse?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor. The client has a new prescription for betamethasone and asks the nurse about the purpose of this medication. Which of the following explanations should the nurse provide?

A nurse in a prenatal clinic is teaching a patient who is in her second trimester and has a new diagnosis of gestational diabetes. Which of the following statements by the patient indicates a need for further teaching?

A nurse is caring for a newborn immediately after birth. Once a patent airway has been ensured, what should be the nurse’s priority action?

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling down and sad, having no energy, and wanting to cry. What should be the nurse’s priority action?

A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant?

A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect?

A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn’s plan of care?

A nurse is caring for a client during the first trimester of pregnancy.
After reviewing the client’s blood work, the nurse notices she does not have immunity to rubella. When should the nurse understand is the recommended time for rubella immunization?