A nurse is caring for a client in the second prenatal visit, the laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data?
The client is immune to the rubella virus.
Administer the first dose of rubella vaccine at this time.
The client is not experiencing a rubella infection at this time
The client requires a rubella immunization in post-partum
The Correct Answer is D
a. A negative rubella titer indicates that the client is not immune to rubella.
b. Rubella vaccine is contraindicated during pregnancy.
c. A negative rubella titer does not indicate whether the client is currently experiencing a rubella infection.
d. A negative rubella titer means that the client does not have antibodies against the rubella virus, which can cause congenital defects in the fetus if the mother gets infected during pregnancy. Therefore, the client should receive the rubella vaccine after delivery, when it is safe to do so.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Bulging of the vulva: This indicates that the fetal head is descending but does not necessarily mean the woman is almost ready to give birth. This indicates that the fetal head is crowning and putting pressure on the perineum, which means that delivery is imminent.
b. This indicates that the amniotic sac has ruptured but does not necessarily mean the woman is almost ready to give birth.
c. The fetal head at 0 station means that it is at the level of the maternal ischial spines, but it still needs to descend further to reach the perineum.
d. This indicates that the woman is in the early stages of labor but does not necessarily mean she is almost ready to give birth.
Correct Answer is A
Explanation
a. The nonstress test is considered reactive if there are two or more accelerations of the fetal heart rate (FHR) in a 20-minute period, lasting 15 seconds or longer and peaking at least 15 beats per minute above the baseline. The FHR baseline is between 110 and 160 beats per minute, with moderate variability. The test is considered nonreactive if these criteria are not met.
b. Turning the client onto her left side is not necessary, as the test is already reactive.
c. Encouraging the client to walk around is not necessary, as the test is already reactive.
d. Notifying the client's provider and preparing for induction of labor is not necessary, as the test is already reactive.
e. Offering the client a snack of orange juice is not necessary, as the test is already reactive.
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