Family History: breast cancer, heart disease. Allergy: Penicillin.
Multiple sexual partners.
A nurse in a prenatal clinic is reviewing the laboratory results for a client who is at 12 weeks of gestation.
Which of the following actions should the nurse take?
Administer rubella vaccine.
Administer ceftriaxone IM.
Obtain a blood culture.
Obtain a maternal serum alpha-fetoprotein specimen.
The Correct Answer is D
The nurse should obtain a maternal serum alpha-fetoprotein (MSAFP) specimen for a client at 12 weeks of gestation.
MSAFP is a screening tool used to identify fetal neural tube defects (NTDs) such as spina bifida and anencephaly.
Elevated levels of MSAFP indicate an increased risk for NTDs, while low levels indicate an increased risk for chromosomal abnormalities such as Down syndrome.
Administering rubella vaccine (A) is contraindicated during pregnancy as it is a live vaccine and can cause fetal harm.
Administering ceftriaxone IM (B) and obtaining a blood culture (C) are not indicated based on the information provided about the client.
The client's allergy to penicillin is not relevant to the nurse's immediate action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should demonstrate how to hold the newborn and allow the client to
practice.
This will help the mother learn how to properly hold her baby and feel more confident in her ability to care for her newborn.
Choice A is not the best answer because insisting that the mother pick up the
newborn to feed him may make her feel uncomfortable or pressured.
Choice C is not the best answer because persuading the client to breastfeed the newborn to promote bonding may not be appropriate if the mother has chosen to botle-feed her baby.
Choice D is not the best answer because offering to take the newborn to the nursery to finish his feeding may not address the mother’s concerns about holding her baby.
Correct Answer is ["A","E"]
Explanation
The nurse should plan to immunize the client with the inactivated influenza vaccine (A) and the diphtheria-acellular pertussis vaccine (E).
The Centers for Disease Control and Prevention (CDC) recommends that pregnant women get two vaccines during every pregnancy: the inactivated flu vaccine and the Tdap vaccine.
The other vaccines listed are not recommended during pregnancy:
- The human papillomavirus vaccine is not recommended during pregnancy.
- The varicella vaccine is not recommended during pregnancy.
- The measles, mumps, and rubella vaccine is not recommended during pregnancy.
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