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
Preparing a vacuum is not the first action to take in this situation. A vacuum-assisted delivery might be considered in some cases, but it’s not the immediate action when the fetal head retracts against the perineum.
Choice B rationale
Applying suprapubic pressure is the correct action. This situation describes shoulder dystocia, where the baby’s shoulder gets stuck behind the mother’s pelvic bone during delivery. Suprapubic pressure can help dislodge the baby’s shoulder and allow the delivery to proceed.
Choice C rationale
Applying fundal pressure is not recommended in this situation. Fundal pressure could potentially worsen shoulder dystocia and is generally avoided.
Choice D rationale
Preparing forceps is not the immediate action to take. Forceps may be used in some delivery situations, but in the case of shoulder dystocia, other maneuvers are tried first.
Correct Answer is D
Explanation
Choice A rationale
Placing a pulse oximeter on the heel of a newborn can help monitor oxygen saturation levels. However, the symptoms described, such as jitteriness, hypotonicity, and a weak cry, are more indicative of hypoglycemia, a condition that would not be detected by a pulse oximeter.
Choice B rationale
Swaddling the infant in a warm blanket can help maintain body temperature, but it does not address the underlying cause of the symptoms, which are suggestive of hypoglycemia.
Choice C rationale
Documenting the findings in the record is an important part of nursing care, but it does not provide immediate intervention for the symptoms observed.
Choice D rationale
Obtaining a heel stick blood glucose level is the appropriate action given the symptoms described. Jitteriness, hypotonicity, and a weak cry can be signs of neonatal hypoglycemia. Prompt diagnosis and treatment are essential to prevent potential complications.
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