The MMR vaccine (measles, mumps, and rubella) is given subcutaneously at a dose of 0.5 mL if the patient is not immune to rubella.
How should the risk of Venous Thromboembolism (VTE) and Postpartum Hemorrhage (PPH) be evaluated?
Low risk: Routine monitoring.
Moderate to high risk: Initiate VTE prophylaxis per policy.
Moderate risk or blood loss greater than 500 mL spontaneous vaginal delivery (SVD) or greater than 1,000 mL cesarean.
High risk: Greater than 500 mL blood loss SVD or greater than 1,000 mL cesarean, vital sign changes.
The Correct Answer is B
Choice A rationale
Low risk: Routine monitoring. This choice is not the most appropriate. While routine monitoring is important for all patients, those receiving the MMR vaccine are not at an increased risk for Venous Thromboembolism (VTE) or Postpartum Hemorrhage (PPH) based solely on the administration of this vaccine.
Choice B rationale
Moderate to high risk: Initiate VTE prophylaxis per policy. This choice is the most appropriate. The risk of VTE and PPH should be evaluated based on the patient’s overall health status, pregnancy history, and current condition. If the patient is determined to be at moderate to high risk, VTE prophylaxis should be initiated per policy.
Choice C rationale
Moderate risk or blood loss greater than 500 mL spontaneous vaginal delivery (SVD) or greater than 1,000 mL cesarean. This choice is not the most appropriate. While these factors can contribute to the risk of VTE and PPH, they are not directly related to the administration of the MMR vaccine.
Choice D rationale
High risk: Greater than 500 mL blood loss SVD or greater than 1,000 mL cesarean, vital sign changes. This choice is not the most appropriate. While these factors can contribute to the risk of VTE and PPH, they are not directly related to the administration of the MMR vaccine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
If the child is sleeping now and is difficult to wake, this could be a sign of worsening respiratory status. Children with respiratory distress often have difficulty sleeping due to discomfort and difficulty breathing. If the child is now sleeping and difficult to wake, this could indicate a decrease in oxygen levels, leading to lethargy and decreased responsiveness. This would require immediate attention.
Choice B rationale
The vital signs provided indicate a potentially serious situation. A heart rate of 130 beats/minute is high for a 3-year-old child, indicating that the heart is working harder to pump blood. A respiratory rate of 15 breaths/minute is on the lower end of normal for a 3-year-old, which could indicate that the child is not getting enough oxygen. An oxygen saturation of 66% on a 5L face mask is dangerously low, indicating severe hypoxia. A temperature of 102.8° F(39.3° C) axillary indicates a fever, which could be a sign of infection. A blood pressure of 92/48 mm Hg is within normal range for a 3-year-old.
Choice C rationale
If the child is active and playing with toys, this could indicate that his respiratory status is not worsening. Children who are experiencing respiratory distress often have difficulty engaging in normal activities due to discomfort and shortness of breath. If the child is able to play normally, this could indicate that he is getting enough oxygen and his condition is stable.
Choice D rationale
If the child’s breathing has returned to normal, this could indicate that his respiratory status is improving. However, it’s important to continue monitoring the child closely, as respiratory conditions can change rapidly, especially in young children.
Correct Answer is B
Explanation
The correct answer is choice A. Manual resuscitation bag and B. An advanced airway kit.
Choice A rationale:
A manual resuscitation bag is essential in pediatric emergencies to provide immediate ventilation support if the child experiences respiratory failure or arrest. This device allows healthcare providers to manually deliver breaths to the patient, ensuring adequate oxygenation and ventilation until more advanced airway management can be established.
Choice B rationale:
An advanced airway kit is crucial for managing a difficult airway, especially in pediatric patients who may have anatomical differences making intubation challenging. This kit typically includes tools for endotracheal intubation, laryngeal mask airways, and other devices to secure the airway and ensure the child can breathe effectively.
Choice C rationale:
A dose of subcutaneous epinephrine is primarily used for treating severe allergic reactions or anaphylaxis. While it is a critical medication in emergencies involving anaphylaxis, it is not directly related to the immediate need for airway management and ventilation in this scenario.
Choice D rationale:
The child’s favorite toy can be helpful in calming and distracting the child during medical procedures, reducing anxiety and making the experience less traumatic. However, it is not a medical necessity for the placement of an intravenous line or for managing respiratory distress.
Choice E rationale:
Nebulized albuterol is used to treat bronchospasm and wheezing, commonly seen in asthma or reactive airway disease. While it is an important medication for managing respiratory symptoms, it does not address the immediate need for airway management and ventilation support in a critical situation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.