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 C

Explanation

The correct answer is choice C. When the neonate responds to the mother by some signal, attachment behavior is stimulated in the mother.This is based on therooting reflex, which helps the baby find the breast or bottle to start feeding and also promotes bonding between the mother and the baby.

Choice A is wrong because acrocyanosis is a normal condition in newborns that causes bluish discoloration of the hands and feet due to poor circulation.It is not related to muscle tone or reflexes.

Choice B is wrong because myelinization of nerves is a process that occurs gradually during development and is not influenced by tactile stimulation.Myelin is a fatty substance that covers nerve fibers and helps them transmit signals faster and more efficiently.

Choice D is wrong because reflexes are involuntary movements or actions that do not depend on conscious thought or learning.They are not directly related to growth patterns, although they may indicate the health and development of the brain and nervous system.

A. “I have begun to smooth cocoa butter on my belly.”. B. “I am resting several times a day, lying on my left side.”. C. “I have started to do nipple stimulation.”. D. “I will drink at least eight glasses of water a day.”.

Correct Answer is C

Explanation

The correct answer is choice C and explain why.Nipple stimulation can cause uterine contractions and increase the risk of preterm labor, especially in a twin gestation.

The client should avoid nipple stimulation until term or as instructed by the provider.

Choice A is wrong because cocoa butter can help moisturize the skin and prevent itching and dryness.

It does not prevent stretch marks, but it is not harmful.

Choice B is wrong because resting several times a day, lying on the left side, can improve blood flow to the uterus and reduce swelling in the lower extremities.

It is a recommended self-care measure for the third trimester of pregnancy.

Choice D is wrong because drinking at least eight glasses of water a day can prevent dehydration, constipation, and urinary tract infections.

It can also help regulate body temperature and amniotic fluid volume.

Normal ranges for twin gestation are similar to singleton gestation, except for fundal height and weight gain.

The fundal height should be measured in centimeters from the pubic symphysis to the top of the uterus.

It should be approximately equal to the number of weeks of gestation plus or minus 4 cm until 32 weeks, then it may plateau or decrease slightly.

The weight gain should be between 35 and 45 pounds for a normal-weight woman, 25 to 42 pounds for an overweight woman, and 15 to 25 pounds for an obese woman.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The mother visits her infant in the nursery. The nurse shows the mother how to place her finger in the palm of the baby’s hand so that the baby will squeeze her finger.This behavior on the nurse’s part reflects an understanding of which principle?

Correct Answer is C

Explanation

A client who is 22 weeks pregnant with a twin gestation comes to the clinic. The nurse instructs the client in self-care for the third trimester of pregnancy. Which statement made by the client would indicate the need for further teaching?

Correct Answer is C

Explanation

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