A nurse is reinforcing teaching with a client who is pregnant and whose routine diagnostic testing reveals a negative rubella titer.
Which of the following statements should the nurse tell the client?
"You had the rubella infection as a child.”.
"I will administer the rubella immunization to you today.”.
"You are immune to rubella.”.
"You will need an immunization following delivery.”.
The Correct Answer is D
A nurse is reinforcing teaching with a client who is pregnant and whose routine diagnostic testing reveals a negative rubella titer. Which of the following statements should the nurse tell the client? The correct answer is choice D: "You will need an immunization following delivery.”.
Choice A rationale:
"You had the rubella infection as a child.”. This statement is incorrect. A negative rubella titer indicates that the client is not immune to rubella. Even if the client had the infection as a child, it does not guarantee immunity for life. Immunity can wane over time, and some individuals may not have developed sufficient immunity after a natural infection.
Choice B rationale:
"I will administer the rubella immunization to you today.”. This statement is not recommended. Rubella vaccination is a live attenuated vaccine, and it is generally contraindicated during pregnancy due to the theoretical risk of transmission to the fetus. Rubella vaccination is usually recommended postpartum if the woman is not immune. The nurse should not administer the vaccine during pregnancy.
Choice C rationale:
"You are immune to rubella.”. This statement is incorrect. A negative rubella titer clearly indicates that the client is not immune to rubella. It's crucial for healthcare providers to provide accurate information to the client and ensure that appropriate immunization is administered postpartum to protect both the mother and the newborn.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The normal sequence of postpartum vaginal discharge, known as lochia, follows this order:
D. Lochia rubra, lochia serosa, lochia alba.
Here's a quick breakdown:
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Lochia rubra (Days 1–4): Bright red discharge with blood, mucus, and tissue.
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Lochia serosa (Days 4–10): Pinkish or brownish discharge as bleeding slows.
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Lochia alba (Days 10–6 weeks): Yellowish-white discharge as the body completes healing.
Correct Answer is A
Explanation
Choice A rationale:
To prevent thrombophlebitis in a postpartum client following a cesarean birth, it is important to promote good circulation and prevent stasis of blood in the lower extremities. Placing pillows under the client's knees while she is resting in bed helps elevate the legs slightly and promotes better venous return, reducing the risk of thrombophlebitis. This position facilitates improved circulation and is a recommended practice.
Choice B rationale:
Applying hot moist soaks to the client's lower legs is not a recommended intervention to prevent thrombophlebitis. In fact, heat can increase inflammation and may worsen the condition. This option would not contribute to the client's plan of care for thrombophlebitis prevention.
Choice C rationale:
Assisting the client to ambulate in the hallway is a good practice to prevent thrombophlebitis, but it may not be suitable for a client who is only 1 day postpartum following a cesarean birth. Early ambulation is encouraged but should be done gradually and at the client's own pace to avoid undue stress on the incision site. Placing pillows under the knees while resting in bed is a more appropriate initial intervention.
Choice D rationale:
Keeping the client on bed rest is not the best option for preventing thrombophlebitis in a postpartum client. Immobility can increase the risk of stasis and clot formation. Promoting circulation, such as elevating the legs with pillows, is a more effective strategy to reduce the risk of thrombophlebitis.
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