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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While providing age-appropriate stimulation is important for all newborns, it is not the priority nursing goal in caring for a newborn with a myelomeningocele awaiting surgery.
Choice B rationale
Educating the parents about the defect is an important part of care, but it is not the priority nursing goal. The immediate physical needs of the newborn take precedence.
Choice C rationale
This is the correct answer. The sac covering the exposed neural tissue must be carefully protected to prevent infection and further damage. Therefore, maintaining the integrity of the sac is the priority nursing goal.
Choice D rationale
Promoting maternal-infant bonding is important, but it is not the priority nursing goal in caring for a newborn with a myelomeningocele awaiting surgery.
Correct Answer is B
Explanation
Choice A rationale
While it’s true that a newborn’s stools will transition in color, it typically takes a few days longer than one or two. Initially, the stools are a greenish-black color known as meconium. Over the next few days, as the baby begins digesting breast milk or formula, the stools will gradually transition to a yellow color.
Choice B rationale
This statement is correct. After childbirth, the breasts undergo a process known as engorgement when they start to produce milk. This can cause the breasts to become harder, warmer, and more tender. This is a normal part of the postpartum period and is a sign that the body is preparing to feed the baby.
Choice C rationale
While it’s true that abdominal discomfort generally decreases over time after childbirth, it’s important to note that the rate of decrease can vary greatly among individuals. Factors such as the type of delivery (vaginal or cesarean), individual pain tolerance, and the presence of any complications can all influence the rate of decrease in abdominal discomfort.
Choice D rationale
While it’s true that many women do feel more energetic as their bodies recover from childbirth, this is not always the case. Factors such as sleep deprivation, hormonal changes, and the physical demands of caring for a newborn can all contribute to feelings of fatigue and exhaustion. Therefore, while some women may feel more energetic, others may continue to feel tired for several weeks or even months after giving birth.
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