A nurse is reinforcing teaching about immunizations with a woman in her first trimester of pregnancy whose diagnostic testing indicates she does not have immunity to rubella. The nurse should recommend that the client receive a measles, mumps, rubella (MMR) vaccine at which of the following times?
When she does not desire future pregnancies
Prior to discharge from the hospital after giving birth
Two weeks before attempting pregnancy again
Prior to giving birth
The Correct Answer is B
Choice A rationale: If the woman does not desire future pregnancies, she may not need the MMR vaccine, but the timing of vaccine administration is not appropriate for the current situation.
Choice B rationale: Administering the MMR vaccine prior to discharge from the hospital after giving birth is recommended during the postpartum period, especially if the woman is planning to have more children in the future.
Choice C rationale: The MMR vaccine contains live attenuated viruses and is contraindicated during pregnancy. If a woman is planning to become pregnant and is not immune to rubella, she should receive the MMR vaccine at least one month before attempting pregnancy. This allows time for her body to develop immunity before conception occurs.
Choice D rationale: The current guidelines from the Centers for Disease Control and Prevention (CDC) advise that the measles, mumps, rubella (MMR) vaccine should not be administered during pregnancy due to possible effects on the uterus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: A positive contraction stress test warrants immediate attention and evaluation. Waiting for 24 hours to repeat the test could delay necessary interventions in case of fetal distress.
Choice B rationale: A positive contraction stress test indicates that there are late decelerations in the baby's heart rate during contractions, which may suggest fetal distress. In such cases, it is essential to admit the client to the hospital for further evaluation, monitoring, and appropriate management.
Choice C rationale: Checking the client's cervix for dilation is not the most appropriate action in response to a positive contraction stress test. Fetal well-being and assessment take priority in this situation.
Choice D rationale: A positive contraction stress test requires further action and should not be considered a routine finding. Proper management and evaluation are necessary when the test results are positive.
Correct Answer is C
Explanation
Choice A rationale:
Turning the client onto her left side is a common measure to improve fetal oxygenation and is often used during labor. However, in this scenario, the nurse needs to address the absence of fetal movement during the nonstress test.
Choice B rationale:
Encouraging the client to walk around and then resume monitoring is not appropriate when there is a concern about the absence of fetal movement during the nonstress test.
Choice C rationale:
Vibroacoustic stimulation involves using sound stimulation to elicit fetal movement. If there has been no fetal movement during the nonstress test, this intervention can be used to assess fetal well-being and provoke a response from the fetus.
Choice D rationale:
Preparing the client for induction of labor is not indicated based solely on the absence of fetal movement during a nonstress test. Further assessment and interventions are needed before considering induction.
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