A nurse is reinforcing teaching about immunizations to a client who is pregnant. Which of the following immunizations should the nurse identity as contraindicated during pregnancy?
Measles, mumps, and rubella
Hepatitis B
Influenza
Diphtheria, tetanus, and pertussis
The Correct Answer is A
A. Measles, mumps, and rubella: The MMR vaccine is a live attenuated vaccine, which is contraindicated during pregnancy due to the risk of fetal infection and teratogenic effects. Pregnant clients should receive this vaccine only after delivery if they are not immune.
B. Hepatitis B: The hepatitis B vaccine is an inactivated vaccine and is considered safe during pregnancy, particularly for clients at increased risk of infection.
C. Influenza: The inactivated influenza vaccine is safe during any trimester of pregnancy and helps protect both the mother and infant from influenza-related complications.
D. Diphtheria, tetanus, and pertussis: The Tdap vaccine is recommended during pregnancy, ideally between 27 and 36 weeks gestation, to confer passive immunity to the newborn.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Copy of the client's advance directives: Advance directives are part of the client’s legal and medical record but are not included in postmortem documentation. Postmortem charting focuses on care provided after death and body identification rather than prior treatment preferences.
B. Cause of the client's death: Determining and documenting the cause of death is the responsibility of the provider, not the nurse. The nurse may document the time death was pronounced and by whom, but listing the cause exceeds the nursing scope of documentation.
C. Location of the identification tag on the client's body: Proper identification is a critical component of postmortem care to ensure correct body handling and prevent errors. Documenting the placement of identification tags supports legal requirements and continuity of care through the morgue and funeral services.
D. Last set of the client's vital signs: Vital signs are not obtained or documented after death has occurred. Postmortem documentation focuses on confirmation of death, care of the body, and disposition rather than physiological measurements.
Correct Answer is A
Explanation
A. Measure the client's abdominal girth daily: Monitoring abdominal girth helps assess the progression or reduction of ascites and guides the effectiveness of interventions such as diuretic therapy or paracentesis. Daily measurements provide objective data for evaluating fluid accumulation.
B. Position the client supine with legs elevated: Elevating the legs while supine is more appropriate for peripheral edema, not ascites. For ascites, semi-Fowler’s or upright positioning is preferred to promote comfort and reduce pressure on the diaphragm.
C. Restrict the client's sodium intake to 3 g per day: Sodium restriction is typically recommended to manage fluid retention in ascites, but standard guidelines suggest limiting sodium to 2 g per day, not 3 g, to optimize effectiveness.
D. Keep the client's daily protein intake below 0.8 g/kg: Clients with cirrhosis and ascites often require adequate protein to prevent muscle wasting and malnutrition. Restricting protein excessively can worsen nutritional status and is generally not recommended unless the client has hepatic encephalopathy.
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