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.”.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:

When a pregnant client is Rh negative and the newborn is Rh positive, it can lead to Rh incompatibility issues. This occurs when fetal Rh-positive red blood cells enter the maternal circulation during pregnancy or childbirth, causing the mother's immune system to produce antibodies against Rh-positive blood cells. To prevent Rh sensitization, Rho(D) immune globulin is administered to Rh-negative pregnant clients at specific times during pregnancy and postpartum. This administration is essential to prevent hemolytic disease of the newborn in future pregnancies. The Rho(D) immune globulin prevents the mother's immune system from developing antibodies against Rh-positive blood cells, ensuring that the current pregnancy and future pregnancies remain safe. Therefore, choice A is the correct answer.

Choice B rationale:

If the client is Rh positive and the newborn is Rh positive, there is no need for Rho(D) immune globulin administration. Rh incompatibility issues only occur when the mother is Rh negative, and the newborn is Rh positive. Therefore, choice B is not the correct answer.

Choice C rationale:

When both the client and the newborn are Rh negative, there is no risk of Rh incompatibility, and therefore, Rho(D) immune globulin administration is unnecessary. This situation is not a reason to administer Rho(D) immune globulin. Choice C is not the correct answer.

Choice D rationale:

If the client is Rh positive and the newborn is Rh negative, there is no risk of Rh incompatibility, and Rho(D) immune globulin administration is not required in this scenario. Choice D is not the correct answer.

A. Heartburn. B. Constipation. C. Urinary urgency. D. Supine hypotension.

Correct Answer is C

Explanation

Choice A rationale:

Heartburn is a common discomfort during pregnancy, but it is not typically associated with the first trimester. Therefore, it is not a relevant manifestation to include in the teaching for a client in the first trimester.

Choice B rationale:

Constipation is a common discomfort in pregnancy, particularly during the first trimester. However, the question specifically asks about first-trimester manifestations, so this choice is not the most appropriate to include in the teaching.

Choice C rationale:

Urinary urgency is a common discomfort during the first trimester of pregnancy due to hormonal changes and the growing uterus pressing on the bladder. This is a relevant manifestation to include in the teaching for a client in the first trimester.

Choice D rationale:

Supine hypotension, also known as aortocaval compression syndrome, is a phenomenon that occurs when a pregnant woman lies flat on her back, compressing the vena cava and reducing blood flow to the heart. It is not typically associated with the first trimester, and it is more commonly a concern in the later stages of pregnancy. Therefore, it is not a relevant manifestation to include in first-trimester teaching.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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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?