A nurse is reinforcing teaching with a client who is postpartum about the measles, mumps, andrubella (MMR) vaccine.

Which of the following instructions should the nurse include in theteaching?

Avoid breastfeeding for 3 days after receiving the vaccine.

Your partner should also receive the MMR vaccine.

If you are allergic to gluten you should not receive this vaccine.

Avoid pregnancy for at least 28 days after receiving the vaccine.

Answer and Explanation

The Correct Answer is D

Explanation:

Avoid pregnancy for at least 28 days after receiving the vaccine: This is a crucial instruction for women of childbearing age. The MMR vaccine is a live attenuated vaccine, and women should avoid becoming pregnant for at least 28 days after receiving it to reduce the theoretical risk to the developing fetus. Pregnant women should not receive the MMR vaccine, and women who receive the vaccine should avoid getting pregnant for at least 28 days afterward.

Incorrect:

A- Avoid breastfeeding for 3 days after receiving the vaccine: This statement is not accurate. Breastfeeding is not contraindicated after receiving the MMR vaccine. In fact, breastfeeding is safe and can be continued as usual.

B- Your partner should also receive the MMR vaccine: While it is essential for individuals to be vaccinated against measles, mumps, and rubella for their own protection and to contribute to herd immunity, it is not a specific instruction given to the postpartum client.

C- If you are allergic to gluten, you should not receive this vaccine: The MMR vaccine does not contain gluten, and a gluten allergy is not a contraindication for receiving the vaccine.

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Correct Answer is D

Explanation

Range-of-motion exercises are within the scope of practice for an AP and do not require specialized nursing knowledge or assessment skills. The AP can assist the client in performing these exercises to promote circulation, maintain joint mobility, and prevent complications associated with immobilization.

Determining the circulation status of the affected extremities, evaluating the need for restraints, and providing education to the client's family about the purpose of restraints require nursing assessment, critical thinking, and communication skills. These tasks should be performed by a licensed nurse who can make clinical judgments and ensure the safety and well-being of the client.

A. Provide the client with a glass of orange juice. B. Instruct the client to take a brisk walk. C. Position the client on their left side. D. Check the client's temperature.

Correct Answer is C

Explanation

Explanation

C. Position the client on their left side

The symptoms of feeling dizzy, racing heart, and becoming pale while lying on their back are consistent with supine hypotensive syndrome or vena cava syndrome. This condition occurs when the pregnant uterus compresses the vena cava, reducing blood flow back to the heart and causing a drop-in blood pressure.

Positioning the client on their left side helps alleviate the pressure on the vena cava, allowing for improved blood flow and preventing further symptoms. This position optimizes blood circulation and reduces the risk of complications. The nurse should assist the client in turning onto their left side and ensure they are comfortable.

Providing the client with a glass of orange juice (option A) is not recommended as it may be helpful in cases of low blood sugar or hypoglycemia, but it is not the most appropriate action in this scenario.

Instructing the client to take a brisk walk (option B) is not recommended since physical exertion can further worsen the symptoms and increase the risk of complications.

Checking the client's temperature (option D) is not necessary as the reported symptoms are not indicative of a fever or infection.

Therefore, the most appropriate action for the nurse to take in this situation is to position the client on their left side (option C).

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A nurse is reinforcing teaching with a client who is postpartum about the measles, mumps, andrubella (MMR) vaccine. Which of the following instructions should the nurse include in theteaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse at a long-term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to an assistive personnel?

Correct Answer is D

Explanation

A nurse is collecting data from a client during a routine prenatal visit. The client is in their second trimester of pregnancy and reports feeling dizzy, has a racing heart, and becomes pale while lying on their back. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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A nurse is reinforcing teaching with a client who is postpartum about the measles, mumps, andrubella (MMR) vaccine.

Which of the following instructions should the nurse include in theteaching?