A 14-year-old client who is pregnant has a low result from a rubella serology test.Which notation should be made on this client’s care plan?

Rubella immunization should be given in the early postpartum period.

Gamma globulin should be given when the client is admitted in labor.

Gamma globulin should be given at next visit.

Rubella immunization should be given at next visit.

Answer and Explanation

The Correct Answer is A

Rubella immunization should be given in the early postpartum period. This is because rubella infection during pregnancy can cause serious birth defects or miscarriage, and rubella vaccine is contraindicated during pregnancy. Therefore, the best time to vaccinate a woman who is not immune to rubella is after she delivers her baby.

Choice B is wrong because gamma globulin is not effective for preventing rubella infection or congenital rubella syndrome (CRS). Gamma globulin is a preparation of antibodies that can provide temporary protection against some infections, but it does not induce lasting immunity.

Choice C is wrong because gamma globulin should not be given at the next visit for the same reason as choice B. Moreover, gamma globulin can interfere with the response to live vaccines such as rubella vaccine, so it should not be given within 3 months before or after vaccination.

Choice D is wrong because rubella immunization should not be given at the next visit or during pregnancy, as it can pose a risk to the fetus. Rubella vaccine is a live attenuated virus vaccine that can cross the placenta and infect the fetus. The risk of CRS from vaccination during pregnancy is low, but it cannot be ruled out completely. Therefore, women who receive rubella vaccine should avoid pregnancy for at least 4 weeks after vaccination.

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Correct Answer is A

Explanation

The correct answer is choice A. The patient has heart disease, and the antibiotics will decrease the risk to her fetus of developing endocarditis.Endocarditis is an infection of the inner lining of the heart and valves, which can be caused by bacteria entering the bloodstream during labor and delivery.Patients with mitral valve prolapse (MVP) are more prone to develop endocarditis because their valve leaflets are floppy and do not close tightly, creating a site for bacterial attachment.Antibiotics can help prevent this complication by killing the bacteria before they reach the heart.

Choice B is wrong because pericarditis is an inflammation of the outer layer of the heart, not the inner lining or valves.It is not related to MVP or bacterial infection.

Choice C is wrong because chorioamnionitis is an infection of the membranes and fluid that surround the fetus, not the heart.It is usually caused by bacteria ascending from the vagina or cervix, not from the bloodstream.

Choice D is wrong because delivering post-term does not increase the risk of systemic infection for the fetus.Systemic infection means infection that affects multiple organs or systems in the body, not just one specific site.

A. The fetal heart rate decreases after the start of a contraction and returns to the baseline 60 seconds after the end of the contraction. B. There is a six to ten beat-to-beat variability in the fetal heart rate. C. The fetal heart rate accelerates five to seven beats just prior to the beginning of a contraction. D. The fetal heart rate decreases at the start of the contraction and returns to baseline by the end of the contraction.

Correct Answer is A

Explanation

The correct answer is choice A and it indicates fetal distress because it is a sign oflate deceleration.Late decelerations are due touteroplacental insufficiencyas the result of decreased blood flow and oxygen to the fetus during the uterine contractions.This causeshypoxemiaand can lead to fetal acidosis and neurological damage.

Choice B is wrong because it indicates anormal variabilityin the fetal heart rate, which reflects a healthy autonomic nervous system.A normal fetal heart rate is 120-160 beats per minute.

Choice C is wrong because it indicates anearly accelerationin the fetal heart rate, which is a benign finding that may occur with fetal movement or stimulation.

Choice D is wrong because it indicates anearly decelerationin the fetal heart rate, which is a normal response to fetal head compression during contractions.

It does not indicate fetal distress.

Normal ranges for fetal heart rate patterns are:

• Baseline: 120-160 beats per minute

• Variability: 6-25 beats per minute

• Accelerations: at least 15 beats per minute above baseline for at least 15 seconds

• Decelerations: none or early (mirror contractions)

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A 14-year-old client who is pregnant has a low result from a rubella serology test.Which notation should be made on this client’s care plan?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse caring for a patient in labor is evaluating the fetal heart monitor.Which finding would indicate fetal distress?

Correct Answer is A

Explanation

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