A nurse is reinforcing teaching with a client who is pregnant and whose routine diagnostic testing reveals a negative rubella titer.
Which of the following statements should the nurse tell the client?
"You had the rubella infection as a child.”.
"I will administer the rubella immunization to you today.”.
"You are immune to rubella.”.
"You will need an immunization following delivery.”.
The Correct Answer is D
A nurse is reinforcing teaching with a client who is pregnant and whose routine diagnostic testing reveals a negative rubella titer. Which of the following statements should the nurse tell the client? The correct answer is choice D: "You will need an immunization following delivery.”.
Choice A rationale:
"You had the rubella infection as a child.”. This statement is incorrect. A negative rubella titer indicates that the client is not immune to rubella. Even if the client had the infection as a child, it does not guarantee immunity for life. Immunity can wane over time, and some individuals may not have developed sufficient immunity after a natural infection.
Choice B rationale:
"I will administer the rubella immunization to you today.”. This statement is not recommended. Rubella vaccination is a live attenuated vaccine, and it is generally contraindicated during pregnancy due to the theoretical risk of transmission to the fetus. Rubella vaccination is usually recommended postpartum if the woman is not immune. The nurse should not administer the vaccine during pregnancy.
Choice C rationale:
"You are immune to rubella.”. This statement is incorrect. A negative rubella titer clearly indicates that the client is not immune to rubella. It's crucial for healthcare providers to provide accurate information to the client and ensure that appropriate immunization is administered postpartum to protect both the mother and the newborn.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice d. Use a postpartum depression-screening tool with the client.
Choice A rationale:
Arranging for counseling is important for long-term support, but the first step is to accurately assess the client’s condition using a screening tool.
Choice B rationale:
Requesting a prescription for an antidepressant may be necessary, but it should follow a proper assessment and diagnosis.
Choice C rationale:
Reinforcing teaching about rest and sleep is beneficial, but it does not address the immediate need to assess the severity of the client’s symptoms.
Choice D rationale:
Using a postpartum depression-screening tool is the first step to identify the severity of the client’s symptoms and determine the appropriate course of action.
Correct Answer is B
Explanation
Choice A rationale:
Maternal/newborn blood group incompatibility can lead to jaundice in newborns, but it typically occurs within the first 24 hours of life. In this scenario, the baby is delivered 12 hours ago, and the yellowing of the skin is described as "slight.”. Physiologic jaundice, which occurs in the majority of newborns, typically appears on the second or third day after birth, so this choice is less likely.
Choice B rationale:
Physiologic jaundice is the most likely cause of the slight yellowing of the newborn's skin. It typically appears on the second or third day after birth and is related to the immature liver's inability to efficiently process bilirubin. Physiologic jaundice is a common and self-limiting condition that does not usually require treatment.
Choice C rationale:
Maternal cocaine abuse can lead to various neonatal complications, but it is not typically associated with jaundice. The yellowing of the skin in this scenario is more likely related to another cause.
Choice D rationale:
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