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.

Answer and Explanation

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.

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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.

A. To prevent herpes infection B. To prevent eye infections C. To clear the infant’s vision D. To dilate the pupil so the red reflex can be visualized E. To dilate the pupil so the red reflex can be viWhat would be the correct response from the nurse regarding the purpose of the ointment?

Correct Answer is B

Explanation

Choice A rationale
While it is true that the ointment can help prevent certain types of infections, it is not specifically intended to prevent herpes infection. Herpes is a viral infection, and the ointment is an antibiotic, which is used to prevent bacterial infections.
Choice B rationale
The primary purpose of eye ointment is to protect newborns from serious eye infections caused by common bacteria. Mothers who have a sexually transmitted infection (STI) can pass it to their newborns during childbirth, putting them at risk for an eye infection known as ophthalmia neonatorum (ON)3.
Choice C rationale
The ointment does not serve to clear the infant’s vision. It is applied to the eyes to prevent bacterial infections, not to improve or alter the infant’s vision.
Choice D rationale
The ointment is not used to dilate the pupil to visualize the red reflex. The red reflex is a reflection from the lining of the eye that is often observed when looking at the pupil, but this is not related to the application of the ointment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is educating parents on how to prevent recurrent otitis media in their infant. What advice should the nurse give?

Correct Answer is D

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A father observing his newborn’s admission to the nursery notices that eye ointment is applied to the infant’s eyes. He asks the nurse about the purpose of the ointment. What would be the correct response from the nurse regarding the purpose of the ointment?

Correct Answer is B

Explanation

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?

A parent rushes their pre-school age child to the emergency department with an asthma exacerbation. Which additional finding should alert the nurse that the child is in acute respiratory distress?

A child who weighs 55 pounds receives a prescription for isoniazid 10 mg/kg/day by mouth (PO) once a day. The bottle is labeled, “Isoniazid Oral Solution, USP 50 mg per 5 mL.”. How many mL should the nurse administer? . .

The nurse is caring for a toddler with a large, unrepaired ventricular septal defect and heart failure. What assessment finding should the nurse anticipate?

During the second stage of labor, the fetal head has just been born and the nurse observes the immediate retraction of the head against the perineum. What action should the nurse anticipate performing to assist the healthcare provider?

The nurse is reviewing the patient’s condition and vital signs following the placement of a 5% dextrose intravenous line. Which medications should the nurse anticipate the healthcare provider will order? Select all that apply.

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?