The MMR vaccine (measles, mumps, and rubella) is given subcutaneously at a dose of 0.5 mL if the patient is not immune to rubella.
How should the risk of Venous Thromboembolism (VTE) and Postpartum Hemorrhage (PPH) be evaluated?

Low risk: Routine monitoring.

Moderate to high risk: Initiate VTE prophylaxis per policy.

Moderate risk or blood loss greater than 500 mL spontaneous vaginal delivery (SVD) or greater than 1,000 mL cesarean.

High risk: Greater than 500 mL blood loss SVD or greater than 1,000 mL cesarean, vital sign changes.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Low risk: Routine monitoring. This choice is not the most appropriate. While routine monitoring is important for all patients, those receiving the MMR vaccine are not at an increased risk for Venous Thromboembolism (VTE) or Postpartum Hemorrhage (PPH) based solely on the administration of this vaccine.
Choice B rationale
Moderate to high risk: Initiate VTE prophylaxis per policy. This choice is the most appropriate. The risk of VTE and PPH should be evaluated based on the patient’s overall health status, pregnancy history, and current condition. If the patient is determined to be at moderate to high risk, VTE prophylaxis should be initiated per policy.
Choice C rationale
Moderate risk or blood loss greater than 500 mL spontaneous vaginal delivery (SVD) or greater than 1,000 mL cesarean. This choice is not the most appropriate. While these factors can contribute to the risk of VTE and PPH, they are not directly related to the administration of the MMR vaccine.
Choice D rationale
High risk: Greater than 500 mL blood loss SVD or greater than 1,000 mL cesarean, vital sign changes. This choice is not the most appropriate. While these factors can contribute to the risk of VTE and PPH, they are not directly related to the administration of the MMR vaccine.

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Correct Answer is A

Explanation

The correct answer is A. Praise the client for her actions and offer to discuss ways to decrease consumption even more.

Why? During pregnancy, any amount of alcohol poses a risk to the developing fetus, but abruptly shaming or forcing action may not be effective. The best approach is motivational interviewing, which involves acknowledging the client's reduction while encouraging further progress. A supportive conversation can help guide the client toward complete cessation of alcohol use.

Here’s why the other options are incorrect:

B. Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit – While alcohol cessation is the goal, forcing the client without a supportive approach can lead to resistance. Routine blood alcohol testing is not standard unless substance dependence is suspected.
C. Notify child protective services of the client’s illicit drug use and probable child endangerment – Alcohol is not classified as an illicit drug, and reporting at this stage would be premature unless clear evidence of abuse or harm to the fetus exists.
D. Refer the client to an outpatient alcohol abuse program for disulfiram therapy – Disulfiram (Antabuse) is not recommended in pregnancy, as it may cause adverse effects. Instead, behavioral counseling and support groups are preferred interventions.

A. Assess for bladder distention. B. Listen for bowel sounds. C. Document the observation. D. Check the scrotum for testicular descent.

Correct Answer is C

Explanation

Choice A rationale
While assessing for bladder distention is important in general urinary assessment, it is not directly related to the observation of the infant voiding a urinary stream from the ventral surface of the penis.
Choice B rationale
Listening for bowel sounds is a part of the general abdominal assessment. However, it does not provide information related to the observation of the infant voiding a urinary stream from the ventral surface of the penis.
Choice C rationale
Documenting the observation is the correct action. The nurse has observed that the infant voids a urinary stream from the ventral surface of the penis. This could indicate a condition such as hypospadias, where the urethral opening is on the underside of the penis. This is an important finding that should be documented and reported.
Choice D rationale
Checking the scrotum for testicular descent is part of the general assessment of the male genitalia. However, it does not provide information related to the observation of the infant voiding a urinary stream from the ventral surface of the penis.

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The MMR vaccine (measles, mumps, and rubella) is given subcutaneously at a dose of 0.5 mL if the patient is not immune to rubella. How should the risk of Venous Thromboembolism (VTE) and Postpartum Hemorrhage (PPH) be evaluated?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client at 9-weeks gestation informs the nurse that she has reduced her alcohol intake but still consumes at least one alcoholic drink every evening before bedtime. What action should the nurse take?

Correct Answer is A

Explanation

The nurse finds that an infant admitted for surgical repair of an inguinal hernia voids a urinary stream from the ventral surface of the penis. What action should the nurse take?

Correct Answer is C

Explanation

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The nurse is providing treatment education to the caregiver of a school-age child recently diagnosed with ADHD. Which statement(s) made by the caregiver demonstrates an understanding?

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The MMR vaccine (measles, mumps, and rubella) is given subcutaneously at a dose of 0.5 mL if the patient is not immune to rubella.
How should the risk of Venous Thromboembolism (VTE) and Postpartum Hemorrhage (PPH) be evaluated?