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 A

Explanation

Allowing the toddler to explore and handle the equipment, such as a stethoscope or blood pressure cuff, can help familiarize them with the objects and reduce anxiety. It can be done under the supervision of the nurse to ensure safety.

Starting the examination with routine immunizations can be helpful because it allows the child to get through potentially uncomfortable or distressing procedures early on. It can also create a positive association between the examination and a sense of relief after receiving vaccinations. While it is important to provide age-appropriate explanations to the toddler, it's essential to keep the explanations simple and concise. Using child-friendly language and demonstrating the procedure using dolls or toys can help the toddler understand what will happen during the examination.

Instead of completely undressing the toddler, it is generally more comfortable and less distressing to only partially undress them. For example, the nurse can ask the caregiver to remove the toddler's shirt while leaving the pants on. This approach helps maintain the child's sense of security and provides a level of modesty.

A. "Soiled dressings should be placed in a biohazard trash receptacle B. "For a client who has Clostridium difficile, I will cleanse my hands with an alcohol-based rub." C. "Droplet precautions require that I wear a gown and gloves when providing client care. D. "Following a blood spill, I should use a bleach solution with a ratio of 1 to 20."

Correct Answer is A

Explanation

Placing soiled dressings in a biohazard trash receptacle is the appropriate practice for disposing of potentially infectious materials. It helps prevent the spread of microorganisms and ensures proper handling and disposal of contaminated items.

Clostridium difficile is a spore-forming bacterium that is not effectively killed by alcohol-based hand rubs. Hand hygiene for C. difficile requires the use of soap and water to thoroughly wash the hands.

Droplet precautions typically require the use of a surgical mask, not a gown and gloves. Gown and gloves are used for contact precautions.

The recommended bleach solution for blood spills is typically a 1:10 dilution, not 1:20. This concentration helps ensure effective disinfection and decontamination of the area.

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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?

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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?