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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

Erythromycin ointment is administered to prevent ophthalmia neonatorum caused by Neisseria gonorrhoeae. Newborns are at risk for eye infections, which can lead to blindness if untreated. Erythromycin ointment provides effective prophylaxis.

Choice B rationale

Neomycin ointment is not indicated for prevention of ophthalmia neonatorum caused by Neisseria gonorrhoeae. It is primarily used for treating minor skin infections and not effective against eye infections in newborns.

Choice C rationale

Tetracaine eye drops are used as a local anesthetic for pain relief during minor eye procedures. They do not provide prophylaxis against ophthalmia neonatorum and are not effective in preventing Neisseria gonorrhoeae eye infections.

Choice D rationale

Latanoprost eye drops are used to treat glaucoma by reducing intraocular pressure. They do not provide prophylaxis against ophthalmia neonatorum and are not effective in preventing Neisseria gonorrhoeae eye infections.

A. Administer a PRN dose of acetaminophen. B. Assess perineum for excessive lochia. C. Document the vital signs in the record. D. Report heart rate to healthcare provider.

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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When is the best time to administer a rubella vaccine to a client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn. Which medication should the nurse administer to the newborn?

Correct Answer is A

Explanation

The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4° F (38° C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?

Correct Answer is C

Explanation

A nurse is caring for a 24-year-old pregnant woman in the prenatal clinic. She is gravida 2, para 1 (G2P1), and her mother has a history of type 2 diabetes mellitus. Exhibits: Exhibits Which is likely causing this client's increased blood glucose at 28 weeks? Select all that apply.

Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?

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