The nurse is discussing a patient’s vaccination history at her 32-week gestation appointment.
The nurse knows that her teaching has been effective when the patient states:
I will go to the clinic to get my rubella shot today.
I will wait until after I have my baby to get my rubella shot.
I had my Tdap shot with my last baby 2 years ago, I do not need another now.
I will hold off on my flu shot this year.
The Correct Answer is B
Choice A rationale
Rubella vaccination is contraindicated during pregnancy due to the live virus, which poses a risk to the fetus. Administration should occur postpartum to avoid congenital rubella syndrome in the infant.
Choice B rationale
This statement is correct as rubella vaccination should be deferred until after delivery. It avoids exposure to the live virus during pregnancy, protecting fetal health.
Choice C rationale
The Tdap vaccine is recommended during each pregnancy, typically between 27 and 36 weeks gestation, to boost maternal antibodies and provide passive immunity to the newborn.
Choice D rationale
The flu vaccine is recommended during pregnancy to protect both the mother and the baby from influenza. It reduces the risk of severe illness and complications from the flu.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Fetal movement felt by the pregnant woman is a presumptive sign of pregnancy, indicating probable fetal presence, but not definitive evidence.
Choice B rationale
Fetal heart rate noted on ultrasound is a positive sign of pregnancy, providing objective evidence of fetal existence within the uterus.
Choice C rationale
A positive pregnancy test indicates probable pregnancy due to hormonal presence, but it is not a definitive confirmation without further clinical evidence.
Choice D rationale
Braxton Hicks contractions are considered probable signs of pregnancy, as they indicate uterine activity without confirming the presence of a fetus.
Correct Answer is B
Explanation
Choice A rationale
The cervix is measured in dilation, not effacement, in centimeters. Effacement is expressed in percentage, indicating the thinning of the cervix.
Choice B rationale
The cervix is 3 cm dilated, 30% effaced, and the presenting part is 2 cm above the ischial spines. This assessment provides a clear status of labor progress.
Choice C rationale
The presenting part being below the ischial spines would be recorded with a positive station, indicating descent into the pelvis, unlike this assessment.
Choice D rationale
The cervix is assessed for dilation in centimeters and effacement in percentage, with station indicating the relationship to the ischial spines.
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