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 D
Explanation
Choice A rationale
While inspecting the infant’s ears daily can help detect signs of an ear infection early, it does not prevent recurrent otitis media.
Choice B rationale
Positioning the infant prone after feeding does not prevent recurrent otitis media and can actually increase the risk of sudden infant death syndrome.
Choice C rationale
While breastfeeding frequently can provide numerous health benefits for the infant, it does not specifically prevent recurrent otitis media.
Choice D rationale
Avoiding exposure to smoke can help prevent recurrent otitis media in infants. Smoke can irritate the Eustachian tubes, which can lead to fluid buildup and increase the risk of ear infections.
Correct Answer is C
Explanation
Choice A rationale
Hypoglycemia, or low blood sugar, is a concern in newborns, but it is not the most immediate concern within the first minutes after delivery.
Choice B rationale
While newborns do have certain bleeding tendencies due to immature clotting mechanisms, this is not the immediate priority in the first minutes after birth.
Choice C rationale
The priority issue that the nurse should address to ensure the newborn’s survival is heat loss.
Newborns are at high risk of heat loss and maintaining their body temperature is crucial. This is because they have a large body surface area relative to their weight and their temperature regulation mechanism is not fully developed.
Choice D rationale
Fluid balance is important in newborns, but it is not the immediate concern in the first minutes after birth. The initial focus is on establishing respiration and maintaining body temperature.
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