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

Blood returning to the right atrium from the pulmonary system is consistent with adult circulation, not fetal circulation. In fetal circulation, blood bypasses the lungs via the ductus arteriosus and foramen ovale since the fetus receives oxygenated blood from the placenta, not the lungs.

Choice B rationale

Blood is returning to the placenta via the umbilical arteries. In fetal circulation, deoxygenated blood is carried from the fetus to the placenta through the umbilical arteries. This is consistent with normal fetal circulation as the placenta is responsible for gas exchange.

Choice C rationale

Blood being shunted to the right side from the left side of the heart is incorrect. In fetal circulation, there is a right-to-left shunt through the foramen ovale, allowing blood to bypass the non-functioning fetal lungs and go directly into systemic circulation.

Choice D rationale

A right-to-left shunt is not seen between the umbilical arteries. Instead, the shunts in fetal circulation are the ductus venosus, ductus arteriosus, and foramen ovale, which help reroute blood away from the fetal lungs and liver.

A. 28-year-old with history of rheumatic heart disease. B. 40-year-old with a history of preterm labor. C. 18-year-old with exposure to HIV. D. 35-year-old with a child with spina bifida.

Correct Answer is D

Explanation

Choice A rationale

While a history of rheumatic heart disease is significant, it does not directly correlate with the need for priority teaching on Quad screening. This condition requires careful cardiac monitoring and management during pregnancy.

Choice B rationale

A history of preterm labor is important and may require additional monitoring and interventions, but it is not a direct indication for priority teaching on Quad screening, which assesses risk for certain fetal conditions.

Choice C rationale

Exposure to HIV requires careful management and monitoring to reduce the risk of mother-to-child transmission. However, it is not specifically linked to the need for Quad screening, which is focused on detecting chromosomal abnormalities.

Choice D rationale

A history of having a child with spina bifida places this client at higher risk for having another child with neural tube defects or chromosomal abnormalities. Therefore, priority teaching on Quad screening, which includes markers for such conditions, is essential. .

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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

After having an ultrasound, the fetus' heart shows that "normal fetal circulation is occurring.”. The RN is teaching a pregnant client about normal fetal circulation.Which of the following statements is consistent with the finding?

Correct Answer is B

Explanation

Each of the following pregnant women is scheduled for a 14-week antepartal visit.In planning care, the nurse would give priority teaching on Quad screening to which client?

Correct Answer is D

Explanation

A male newborn is diagnosed with polycystic kidneys which requires autosomal dominant transmission.One of the parents is believed to have this genetic disease. The nurse's teaching should be based on the fact that with autosomal dominant inheritance:

A nurse is teaching a client that is HIV positive about HIV treatment.The client is 16 weeks pregnant.Which statement made by the client indicates that she needs more teaching?

A client reports that she and her husband are considering starting a family within the next year.The nurse should advise the client to increase her intake of folic acid:

A nurse is speaking with a client who is 6 weeks' gestation.The client tells the nurse that she smokes one pack per day, but is trying to quit.The nurse should explain that newborns born to women who smoke are at risk for:

A pregnant client tells the nurse that her LMP was 3 months ago and began on October 20. Using Naegele's rule, calculate the client's estimated date of delivery. Answer format E.g. "October 20"

The nurse is teaching a pregnant client how to perform daily fetal movement counts.Which instruction must be included in the teaching?

A client is 10 weeks pregnant and is experiencing nausea each day.Which strategy would the nurse NOT recommend to the client?

For each potential prescription from the provider, specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

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?