A nurse is reviewing a client's rubella titer of 1:8 at her second prenatal visit.
Which of the following statements by the nurse is appropriate?
"You will need a rubella immunization at your next prenatal visit.”.
"Because rubella is a live vaccine, you will not be able to breastfeed your newborn.”.
"Your titer indicates that you are susceptible to rubella.”.
"During your third trimester, you will need to repeat a blood test for the titer.”.
The Correct Answer is C
Choice A rationale
Administering a rubella immunization during pregnancy is contraindicated because the rubella vaccine is a live attenuated virus vaccine. There is a theoretical risk of viral transmission to the fetus, which could lead to congenital rubella syndrome. Vaccination should occur postpartum to protect future pregnancies.
Choice B rationale
Breastfeeding is not contraindicated after receiving the rubella vaccine. Although rubella vaccine virus can be excreted in breast milk, it generally does not cause clinical illness in the infant and passive transfer of antibodies may provide some protection to the infant.
Choice C rationale
A rubella titer of 1: indicates a low level of rubella antibodies, meaning the client is susceptible to rubella infection. A titer of less than 1: or 1: is generally considered non-immune, requiring vaccination to prevent congenital rubella syndrome in future pregnancies.
Choice D rationale
Repeating a rubella titer in the third trimester is not a standard practice for assessing susceptibility. Once susceptibility is determined, the primary intervention is postpartum vaccination. The initial titer result accurately reflects immune status and further testing during pregnancy is unnecessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Immediately bathing a newborn with herpes simplex virus is generally discouraged. While it might seem intuitive for infection control, vigorous bathing could theoretically disrupt skin integrity and potentially spread the virus to other areas of the body or mucous membranes, exacerbating the infection.
Choice B rationale
Initiating contact precautions is essential for a newborn with herpes simplex virus. This highly contagious viral infection requires strict measures to prevent transmission to other vulnerable neonates and healthcare providers. Contact precautions involve gown and glove use, limiting direct contact with the newborn or contaminated surfaces.
Choice C rationale
Administering ampicillin IV is not the appropriate treatment for herpes simplex virus. Ampicillin is an antibiotic effective against bacterial infections, not viral infections like herpes simplex. Antiviral medications, such as acyclovir, are the specific treatment for neonatal herpes simplex virus to inhibit viral replication.
Choice D rationale
Withholding breastfeeding is not typically indicated for a newborn with in utero transmitted herpes simplex virus unless the mother has active lesions on her breasts. The primary concern is direct skin-to-skin transmission if lesions are present. Breast milk itself provides beneficial antibodies and is not a route of transmission for in utero infection.
Correct Answer is A
Explanation
Choice A rationale
The lecithin/sphingomyelin (L/S) ratio test is a crucial assessment of fetal lung maturity. Lecithin and sphingomyelin are phospholipids that are components of surfactant, a substance vital for reducing surface tension in the alveoli and preventing lung collapse at birth. A ratio of 2: or greater generally indicates adequate lung maturity.
Choice B rationale
The L/S ratio test does not assess the baby's blood type. Fetal blood typing is determined through other methods, such as cordocentesis or maternal blood tests for fetal DNA, if clinically indicated. The L/S ratio specifically evaluates the quantity and ratio of pulmonary surfactants.
Choice C rationale
This test does not check the baby's liver development. Fetal liver development is assessed through different parameters, such as ultrasound visualization of liver size, blood flow characteristics, and specific liver enzyme levels if a concern exists. The L/S ratio is solely focused on pulmonary maturity.
Choice D rationale
The L/S ratio test is not used to check for genetic disorders. Genetic disorders are identified through chromosomal analysis, DNA sequencing, or biochemical tests performed on amniotic fluid cells obtained during amniocentesis, or through chorionic villus sampling. The L/S ratio is a physiological marker of lung readiness.
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