A nurse is caring for a client in the first trimester of pregnancy and discovers that the client lacks immunity to rubella based on her blood work. When is the recommended time for administering rubella immunization?
During the next attempt to get pregnant
Immediately after delivery
During the third trimester of pregnancy
During the first trimester of pregnancy
The Correct Answer is B
A. During the next attempt to get pregnant
This is incorrect because waiting until the next pregnancy increases the risk of congenital rubella syndrome in future pregnancies. The vaccine should be given immediately postpartum to provide immunity.
B. Immediately after delivery
This is correct because the rubella vaccine (MMR) is a live vaccine and is contraindicated during pregnancy due to teratogenic effects. It should be given postpartum before hospital discharge to prevent future rubella infections.
C. During the third trimester of pregnancy
This is incorrect because live vaccines are contraindicated in pregnancy due to the risk of fetal infection.
D. During the first trimester of pregnancy
This is incorrect because administering a live vaccine early in pregnancy is dangerous and could cause fetal harm or congenital anomalies.
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Related Questions
Correct Answer is B
Explanation
A. During the next attempt to get pregnant
This is incorrect because waiting until the next pregnancy increases the risk of congenital rubella syndrome in future pregnancies. The vaccine should be given immediately postpartum to provide immunity.
B. Immediately after delivery
This is correct because the rubella vaccine (MMR) is a live vaccine and is contraindicated during pregnancy due to teratogenic effects. It should be given postpartum before hospital discharge to prevent future rubella infections.
C. During the third trimester of pregnancy
This is incorrect because live vaccines are contraindicated in pregnancy due to the risk of fetal infection.
D. During the first trimester of pregnancy
This is incorrect because administering a live vaccine early in pregnancy is dangerous and could cause fetal harm or congenital anomalies.
Correct Answer is C
Explanation
A. "Presence of late decelerations with each contraction during monitoring."
Late decelerations indicate uteroplacental insufficiency, which can lead to fetal hypoxia and distress. This is not a reassuring sign.
B. "Increased fetal movement between contractions."
While fetal movement is a positive sign, it is not the best indicator of fetal well-being in labor. Continuous FHR monitoring provides a better assessment.
C. "Fetal heart rate of 160 beats per minute with moderate variability."
A normal fetal heart rate (FHR) is 110–160 bpm, and moderate variability (6–25 bpm fluctuations) indicates a well-oxygenated fetus with an intact autonomic nervous system.
D. "Fetal heart rate consistently below 120 beats per minute with no accelerations."
A persistent FHR below 110 bpm (bradycardia) or minimal variability suggests possible fetal compromise.
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