A nurse is caring for a client during the first trimester of pregnancy.
After reviewing the client’s blood work, the nurse notices she does not have immunity to rubella. When should the nurse understand is the recommended time for rubella immunization?

Shortly after giving birth.

During her next attempt to get pregnant.

Immediately in the third trimester.

During the second trimester.

Answer and Explanation

The Correct Answer is A

Choice A rationale

The recommended time for rubella immunization for a woman who does not have immunity is shortly after giving birth. The MMR vaccine, which protects against measles, mumps, and rubella, is a live virus vaccine and is not recommended during pregnancy.

Choice B rationale

While it’s important for a woman to have immunity to rubella before her next pregnancy, waiting until her next attempt to get pregnant to get the vaccine could potentially leave her unprotected if she becomes pregnant sooner than planned.

Choice C rationale

The MMR vaccine is not recommended during pregnancy, including in the third trimester.

Choice D rationale

The MMR vaccine is not recommended during pregnancy, including in the second trimester.

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Correct Answer is D

Explanation

The correct answer is Choice D.

Choice A rationale: Having the client pant during the next contractions helps to prevent premature pushing. Panting, or controlled breathing, reduces the urge to bear down, which can help prevent cervical swelling or tearing until full dilation is achieved.

Choice B rationale: Assisting the client into a comfortable position is important but not the immediate priority. The client should be instructed to use techniques to prevent pushing.

Choice C rationale: Helping the client to the bathroom to void is not appropriate at this stage of labor, as it may increase the risk of complications and is not the immediate priority.

Choice D rationale: Observing the perineum for signs of crowning is crucial. This action helps the nurse determine if the client is indeed ready to push and if the baby is descending properly. It ensures that the timing for pushing is optimal to prevent complications during delivery.

A. Body temperature. B. Respiratory assessment. C. Serum glucose level. D. White blood cell count.

Correct Answer is C

Explanation

Hypoglycemia, or low blood sugar, is a common condition in newborns, especially those born to mothers with diabetes, those who are small for their gestational age, or those who have been stressed during birth. It’s important to monitor the newborn’s serum glucose level and report any abnormalities to the healthcare provider.

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A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client’s blood work, the nurse notices she does not have immunity to rubella. When should the nurse understand is the recommended time for rubella immunization?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client’s amniotic membranes are intact. The client suddenly states that she needs to push. What action should the nurse take?

Correct Answer is D

Explanation

A nurse is attending to a newborn 2 hours after birth. Which four observations should the nurse report to the healthcare provider?

Correct Answer is C

Explanation

A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis?

A nurse is caring for a client who is a primigravida, at term, and having contractions but is unsure if she is in labor. Which of the following should the nurse recognize as a sign of true labor?

A nurse is admitting an 8-hour-old, term newborn following a cesarean birth. The nurse observes that the newborn’s skin is yellow. This finding indicates the newborn is experiencing a complication related to which of the following?

A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect?

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant?

A nurse is monitoring a client who is receiving magnesium sulfate to manage preeclampsia. Which of the following observations should the nurse immediately report to the healthcare provider?

A nurse is caring for a newborn who is 30 minutes old. After reviewing the information in the newborn’s medical record, which of the following complications should the nurse identify as posing the greatest risk?

A nurse is caring for a client during the first trimester of pregnancy.
After reviewing the client’s blood work, the nurse notices she does not have immunity to rubella. When should the nurse understand is the recommended time for rubella immunization?