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 C

Explanation

Choice A rationale

Increasing IV infusion rate can exacerbate fluid overload and hypertension, potentially worsening the patient's condition. Monitoring fluid status and adjusting infusions cautiously is critical to avoid iatrogenic complications.

Choice B rationale

Assessing vital signs helps detect early signs of complications such as hypovolemia, infection, or abnormal bleeding, facilitating timely intervention to prevent further deterioration.

Choice C rationale

Massaging the fundus promotes uterine contraction, reducing the risk of postpartum hemorrhage. Effective fundal massage can control bleeding and stabilize the patient following childbirth.

Choice D rationale

Notifying the healthcare provider ensures prompt communication of any changes in the patient's condition, enabling timely medical intervention and potentially preventing adverse outcomes.

A. Heart rate of 56 beats/minute. B. Saturating two perineal pads per hour. C. Soft, spongy fundus. D. Unilateral lower leg pain.

Correct Answer is A

Explanation

Choice A rationale

Bradycardia (heart rate 56 beats/minute) is common postpartum due to increased stroke volume and reduced heart rate, reflecting physiological adaptation after delivery.

Choice B rationale

Saturating two perineal pads per hour is excessive and could indicate postpartum hemorrhage, requiring immediate evaluation and intervention.

Choice C rationale

A soft, spongy fundus indicates uterine atony, a serious condition requiring urgent intervention to prevent postpartum hemorrhage.

Choice D rationale

Unilateral lower leg pain could indicate deep vein thrombosis (DVT), a significant postpartum complication needing immediate medical attention.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which action is most important for the nurse to implement?

Correct Answer is C

Explanation

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

Correct Answer is A

Explanation

Which action should the nurse take?

After two miscarriages, a client is instructed to increase her daily intake of foods that includes folic acid. The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?

A woman who is trying to get pregnant tells the nurse that she was very disappointed several months ago when she was informed that her positive pregnancy test was a false positive. Which method of determining pregnancy provides the greatest degree of accuracy?

A newborn is delivered by cesarean section to a mother who is HIV-positive. The mother received antiretroviral therapy during pregnancy. Which intervention should the nurse implement?

A client at 9 weeks gestation tells the nurse that while she has cut down, she still has at least one alcoholic drink every evening before bedtime. Which intervention should the nurse implement?

A primigravida client who is at 33 weeks gestation presents to the labor and delivery unit troubled with a headache. The initial assessment findings include a blood pressure of 144/96 mm Hg, facial edema, and 3+ pitting edema in lower extremities. Which assessment should the nurse perform next?