A nurse is reinforcing teaching about immunizations with a woman in her first trimester of pregnancy whose diagnostic testing indicates she does not have immunity to rubella. The nurse should recommend that the client receive a measles, mumps, rubella (MMR) vaccine at which of the following times?

When she does not desire future pregnancies

Prior to discharge from the hospital after giving birth

Two weeks before attempting pregnancy again

Prior to giving birth

Answer and Explanation

The Correct Answer is B

Choice A rationale: If the woman does not desire future pregnancies, she may not need the MMR vaccine, but the timing of vaccine administration is not appropriate for the current situation.
Choice B rationale: Administering the MMR vaccine prior to discharge from the hospital after giving birth is recommended during the postpartum period, especially if the woman is planning to have more children in the future.
Choice C rationale: The MMR vaccine contains live attenuated viruses and is contraindicated during pregnancy. If a woman is planning to become pregnant and is not immune to rubella, she should receive the MMR vaccine at least one month before attempting pregnancy. This allows time for her body to develop immunity before conception occurs.
Choice D rationale: The current guidelines from the Centers for Disease Control and Prevention (CDC) advise that the measles, mumps, rubella (MMR) vaccine should not be administered during pregnancy due to possible effects on the uterus.

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Correct Answer is D

Explanation

Choice A rationale: This response is not supportive and may cause the client to feel pressured or inadequate. It is essential to be empathetic and understanding of the client's feelings and needs.
Choice B rationale: The nurse should encourage the client to begin breastfeeding and offer support if needed. This response does not promote the client's active involvement in caring for her newborn.
Choice C rationale: While breastfeeding is a natural process, it can be challenging for some women, especially in the early days. This response may minimize the client's concerns and emotions.
Choice D rationale: The nurse should be supportive and reassuring to the postpartum client. The client may be feeling overwhelmed or uncertain about breastfeeding, so offering assistance and staying with the client to help with the first feeding is an appropriate and compassionate response.

A. "The best way to determine if your baby can hear is to clap your hands loudly and see if she startles." B. "There is no need to worry about that. Most forms of hearing loss are not Inherited." C. "We do routine hearing screenings on newborns. You'll know the results before you leave the hospital." D. "Look at how she looks as you when you speak. That's a good sign."

Correct Answer is C

Explanation

Choice A rationale: This statement is not accurate, as startling in response to a loud noise does not necessarily indicate that the baby can hear normally. Startling can be a normal reflex response and may not accurately assess the baby's hearing ability.
Choice B rationale: While it is true that many forms of hearing loss are not inherited, the client's concern about her family history of deafness is valid. It is essential to address her concerns and provide appropriate information about the hearing screening.
Choice C rationale: Routine hearing screenings are typically performed on newborns to identify any potential hearing problems early on. Early detection and intervention for hearing loss can lead to better outcomes for the baby's language development and overall well-being. By reassuring the client about the hearing screening, the nurse addresses her concerns and provides information about the process.
Choice D rationale: While visual cues and responses are important for the baby's communication and bonding, they do not provide a definitive assessment of the baby's hearing ability. Hearing screening is a more reliable method to detect potential hearing problems in newborns.

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A nurse is reinforcing teaching about immunizations with a woman in her first trimester of pregnancy whose diagnostic testing indicates she does not have immunity to rubella. The nurse should recommend that the client receive a measles, mumps, rubella (MMR) vaccine at which of the following times?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a postpartum client and her newborn. The client asks the nurse to feed the newborn. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is caring for a client who is postpartum. The client states, "I am concerned about my baby's hearing because my mother was born deaf." Which of the following statements should the nurse make?

Correct Answer is C

Explanation

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