A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data?
The client requires a rubella vaccination at this time.
The client is not experiencing a rubella infection at this time.
The client requires a rubella immunization following delivery.
The client is immune to the rubella virus.
The Correct Answer is C
A. The client requires a rubella vaccination at this time. This is incorrect because rubella vaccination is contraindicated during pregnancy due to the risk of congenital rubella syndrome. Vaccination should be administered postpartum.
B. The client is not experiencing a rubella infection at this time. While this statement is true, it does not address the need for future immunization, which is the critical aspect of the interpretation.
C. The client requires a rubella immunization following delivery. This is correct because a negative rubella titer indicates that the client is not immune to rubella and should receive the vaccine postpartum to prevent future infection.
D. The client is immune to the rubella virus. This is incorrect because a negative rubella titer indicates a lack of immunity to rubella, meaning the client is susceptible to infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: At 7 cm dilation, the client is in active labor, and assisting her into a more comfortable position may not be appropriate at this stage. It is essential to observe for signs of impending birth and assess the progress of labor.
Choice B: Feeling the urge to push may indicate that the baby is descending and the cervix is fully dilated. The nurse should immediately observe the perineum for signs of crowning (when the baby's head starts to appear at the vaginal opening) to prepare for delivery.
Choice C: If the client is feeling the urge to push and the cervix is fully dilated, panting or blowing through contractions will not be effective. It is important to allow the client to follow her body's natural urges to push.
Choice D: While emptying the bladder is generally recommended during labor to provide more room for the baby to descend, the client's current urge to push suggests that the baby is likely in a lower position, and it might not be safe or feasible to move the client to the bathroom.
Correct Answer is A
Explanation
Choice A: The client should not lie on her back during the NST because the supine position can compress the vena cava and reduce blood flow to the placenta and the baby. The NST is typically done with the client in a semireclined or left lateral position to ensure optimal blood flow to the baby.
Choice B: Monitoring the baby's heart rate is a correct statement and a standard part of the NST procedure.
Choice C: The duration mentioned (20 to 30 minutes) is accurate for the average NST timeframe.
Choice D: Scheduling the NST when the baby is usually active is also a correct statement, as fetal movement during the test is an important aspect of evaluating fetal wellbeing.
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