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 D
Explanation
Choice A rationale
During pregnancy, the body’s production of red blood cells usually increases to meet the increased demands of the growing fetus. Therefore, a drop in hematocrit is not typically due to insufficient red blood cell production.
Choice B rationale
While iron is essential during pregnancy, a reduction in hematocrit levels at 16 weeks' gestation is primarily due to increased plasma volume, rather than iron deficiency. Nutritional counseling may still be beneficial but isn't the primary explanation for this change.
Choice C rationale
A hematocrit level of 34% at 16 weeks is generally not considered indicative of a severe problem. Instead, it is a physiological response to increased plasma volume, known as dilutional anemia of pregnancy.
Choice D rationale
The primary reason for a lower hematocrit count during pregnancy is the increase in blood plasma volume, leading to dilutional anemia. This is a normal adaptation to pregnancy that ensures adequate blood flow to the fetus.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
The correct answer is:
A. Anticipated.
B. Nonessential.
C. Anticipated.
D. Anticipated.
E. Anticipated.
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