When is the best time to administer a rubella vaccine to a client?
After the client reaches 20-weeks gestation.
Immediately, at 6-weeks gestation, to protect this fetus.
Early postpartum, within 72 hours after delivery.
After the client stops breastfeeding.
The Correct Answer is C
Choice A rationale
Administering the rubella vaccine after 20-weeks gestation is inappropriate as it is a live vaccine, which poses potential risks to the fetus. The vaccine is contraindicated during pregnancy due to teratogenic effects.
Choice B rationale
Administering the rubella vaccine at 6-weeks gestation is contraindicated because it is a live vaccine. Live vaccines pose risks to the fetus and are not recommended during pregnancy due to potential teratogenicity.
Choice C rationale
Administering the rubella vaccine early postpartum within 72 hours after delivery is recommended. This timing ensures the mother is not pregnant and reduces the risk of congenital rubella syndrome in future pregnancies.
Choice D rationale
Waiting until the client stops breastfeeding is unnecessary. The rubella vaccine can be safely administered during breastfeeding, as it does not pose a risk to the infant or affect milk production.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Starting IV fluids is essential but not the priority in this situation. Caffeine intake may alter anesthesia effects, and the anesthesiologist needs to be informed first.
Choice B rationale
Informing the anesthesia care provider is crucial because caffeine can affect anesthesia administration and increase the risk of complications, such as increased gastric acidity and delayed gastric emptying.
Choice C rationale
Ensuring preoperative lab results is important, but it is not the immediate priority compared to informing the anesthesia care provider about the caffeine intake, which directly impacts anesthesia management.
Choice D rationale
Contacting the obstetrician is necessary but secondary. The immediate priority is to inform the anesthesia care provider about the caffeine intake, which has direct implications for anesthesia and surgical safety.
Correct Answer is C
Explanation
Choice A rationale
Administering acetaminophen is not indicated as the temperature of 100.4° F (38° C) is within the normal postpartum range, often due to dehydration or breast engorgement. Acetaminophen should be used cautiously and only if necessary.
Choice B rationale
Assessing perineum for excessive lochia is unnecessary here, as the current vital signs do not indicate hemorrhage. Normal postpartum bleeding gradually decreases in amount and should be monitored accordingly but not prompted by these vitals.
Choice C rationale
Documentation of vital signs is essential to maintain accurate medical records and track any changes in the patient's condition. Accurate records help in identifying trends and making informed decisions about patient care.
Choice D rationale
Reporting a heart rate of 58 beats/minute is unnecessary because bradycardia can be normal in postpartum women, especially if they have good cardiovascular fitness. It is important to monitor for other symptoms before taking further action.
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