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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale

At 16 weeks, the fundal height is typically below the umbilicus. This location is more indicative of a fetus at around 20 weeks.

Choice B rationale

At 20 weeks, the fundal height is usually at the level of the umbilicus, indicating this is the correct gestational age.

Choice C rationale

At 24 weeks, the fundal height is usually above the umbilicus, suggesting a more advanced gestation than the picture indicates.

Choice D rationale

At 28 weeks, the fundal height is significantly above the umbilicus, making this option incorrect for the given scenario.

A. Hepatitis B immune globulin at 1 week followed by hepatitis B vaccine monthly for 6 months. B. Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth. C. Hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen. D. Hepatitis B vaccine at 24 hr followed by hepatitis B immune globulin every 12 hr for 3 days.

Correct Answer is B

Explanation

Choice A rationale

Hepatitis B immune globulin at 1 week followed by hepatitis B vaccine monthly for 6 months is incorrect. This schedule delays the immune response and leaves the infant unprotected during the critical early period when the risk of transmission is highest.

Choice B rationale

Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth is the correct approach. This combination provides immediate passive immunity through the immune globulin and active immunity through the vaccine, significantly reducing the risk of hepatitis B transmission from mother to child.

Choice C rationale

Hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen is incorrect. Monthly administration alone is insufficient without the initial dose of immune globulin, especially since the infant may remain at risk until the negative test result.

Choice D rationale

Hepatitis B vaccine at 24 hr followed by hepatitis B immune globulin every 12 hr for 3 days is incorrect. The delay in the first vaccine dose reduces its efficacy, and the immune globulin schedule does not align with established guidelines for preventing hepatitis B transmission.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse who is assessing a G2 P1 client palpates the fundal height at the location noted on the picture below (near the umbilicus). The nurse concludes that the fetus is equal to which of the following gestational ages?

Correct Answer is B

Explanation

A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen.Which of the following should the infant receive?

Correct Answer is B

Explanation

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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?