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 A
Explanation
Choice A rationale
Visualization of implantation by vaginal ultrasound offers the highest accuracy in confirming pregnancy, as it directly visualizes the implanted embryo, eliminating errors associated with biochemical tests.
Choice B rationale
Maternal blood serum tests positive for alpha-fetoprotein do not confirm pregnancy. Alpha-fetoprotein is a marker used primarily for screening fetal abnormalities, not pregnancy determination.
Choice C rationale
The presence of amenorrhea for 2 months can suggest pregnancy but is not definitive due to other potential causes of missed periods, such as hormonal imbalances or stress, reducing its accuracy.
Choice D rationale
Reporting feeling tired all the time is a nonspecific symptom that can result from numerous conditions unrelated to pregnancy, making it an unreliable method for pregnancy determination.
Correct Answer is []
Explanation
Rationale for correct condition: Hypoglycemia in neonates can present with jitteriness, low body temperature, and poor feeding. Normal blood glucose levels for neonates range from 40-60 mg/dL. The Ballard maturity rating of 37 weeks indicates that the neonate may have an immature glucose metabolism. Early recognition and treatment are crucial to prevent complications.
Rationale for correct actions:
- Giving dextrose solution orally quickly increases blood glucose levels. This provides an immediate source of glucose to the neonate.
- Performing a heel stick for blood glucose testing allows for accurate monitoring of glucose levels. Continuous assessment ensures timely intervention.
Rationale for correct parameters:
- Blood glucose levels: Monitoring ensures that the neonate maintains normal glucose levels (40-60 mg/dL). This helps prevent hypoglycemia-related complications.
- Temperature: Neonates with hypoglycemia often have low body temperature. Monitoring temperature aids in detecting and addressing hypothermia.
Rationale for incorrect conditions:
- Altered respiratory function: The neonate has normal respiratory rate and heart rate.
- Thermoregulation: Although temperature is low, the jitteriness is more indicative of hypoglycemia.
- Sepsis: No signs of infection such as fever or elevated white blood cell count are present.
Rationale for incorrect actions:
- Provide manual breaths with a bag-valve mask: Not necessary as the neonate's respiratory rate is normal.
- Administer intravenous antibiotics: No signs of infection or sepsis.
- Place the neonate under a radiant warmer: This addresses temperature but not blood glucose levels.
Rationale for incorrect parameters:
- Respiratory rate: Normal, does not indicate hypoglycemia.
- Oxygen saturation: No signs of respiratory distress.
- Bilirubin levels: Not relevant to the current symptoms.
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