You, the RN, assess a client who is in the 32nd week of pregnancy.
She fell and punctured her leg with a nail.
She states she has not had a tetanus immunization since infancy.
Which action will you include in her plan of care?
Analysis of her serum for tetanus antibodies.
Administration of tetanus immune globulin now.
Inducing labor to avoid tetanus in the fetus.
Administration of tetanus immune globulin after delivery.
The Correct Answer is B
Choice A rationale
Analysis of serum for tetanus antibodies is not an immediate action in acute injury scenarios. The priority is to provide immediate passive immunity.
Choice B rationale
Administration of tetanus immune globulin provides immediate passive immunity. This is crucial to prevent tetanus infection since the client has not been immunized since infancy.
Choice C rationale
Inducing labor to avoid tetanus in the fetus is not a recommended action. The focus should be on providing immediate protection to the mother to prevent infection.
Choice D rationale
Administration of tetanus immune globulin after delivery delays necessary immediate protection. The risk of tetanus infection is immediate, so prompt administration is required.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
Choice A Rationale
Administer azithromycin 1 g PO one time: Anticipated. Azithromycin is commonly used to treat chlamydia infections during pregnancy and is considered safe.
Choice B Rationale
Administer ibuprofen 600 mg PO twice a day for pain: Contraindicated. Ibuprofen is generally avoided during pregnancy, especially in the third trimester, due to risks such as premature closure of the fetal ductus arteriosus.
Choice C Rationale
Notify all sexual partners within prior 30 days of the need for STI screening: Anticipated. Notification of sexual partners for STI screening is a standard public health practice to prevent the spread of infections.
Choice D Rationale
Administer ceftriaxone 250 mg IM now: Anticipated. Ceftriaxone is often used to treat gonorrhea infections during pregnancy and is considered safe for both mother and fetus.
Choice E Rationale
Repeat STI screening at next prenatal visit in 1 month: Anticipated. Repeating STI screening can help ensure that any new or untreated infections are identified and managed appropriately.
Choice F Rationale
Notify the appropriate public health agency: Anticipated. Reporting certain STIs to public health agencies is required by law to help track and control the spread of infections.
Correct Answer is A
Explanation
Choice A rationale
At 9 weeks gestation, the primary purpose of an ultrasound is to confirm the presence of a fetal heartbeat, which indicates a viable pregnancy.
Choice B rationale
Chromosomal defects are typically assessed using different tests, such as chorionic villus sampling or amniocentesis, rather than an ultrasound at this early stage.
Choice C rationale
Fetal lung maturity cannot be assessed at 9 weeks gestation because the lungs are not yet developed. This assessment is usually done later in pregnancy if preterm delivery is anticipated.
Choice D rationale
The position of the fetus in utero is not a concern at this early stage of pregnancy. Fetal positioning becomes relevant later in pregnancy, closer to delivery.
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