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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Bilirubin levels are typically monitored by a healthcare professional and not by parents at home every 6 hours. The frequency of bilirubin checks for a newborn receiving home phototherapy is usually determined by the healthcare provider based on the infant's bilirubin trajectory and clinical status, often daily or as prescribed.
Choice B rationale
Offering glucose water to newborns is not recommended. Glucose water does not provide adequate nutrition and can interfere with successful breastfeeding or formula feeding by reducing the infant's appetite for nutrient-rich milk. Adequate hydration and nutrition are crucial for bilirubin excretion in jaundiced infants.
Choice C rationale
For biliblanket phototherapy, eye coverings are generally not necessary. The biliblanket emits light from a fiber optic pad that is wrapped around the infant's body, and the light does not directly shine into the baby's eyes, unlike traditional overhead phototherapy lights that require eye protection.
Choice D rationale
Removing the baby from the biliblanket for feedings is appropriate and encouraged. Intermittent breaks for feeding and bonding are permissible as long as the total duration of phototherapy prescribed by the healthcare provider is met. Frequent feedings promote bilirubin excretion through stools.
Correct Answer is A,B,C,D
Explanation
Observe the newborn's respirations. Auscultate the newborn's heart rate. Auscultate newborn's abdomen. Test the newborn's reflexes.
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