You, the RN, assess a client who is in the 32nd week of pregnancy.
She fell and punctured her leg with a nail.
She states she has not had a tetanus immunization since infancy.
Which action will you include in her plan of care?
Analysis of her serum for tetanus antibodies.
Administration of tetanus immune globulin now.
Inducing labor to avoid tetanus in the fetus.
Administration of tetanus immune globulin after delivery.
The Correct Answer is B
Choice A rationale
Analysis of serum for tetanus antibodies is not an immediate action in acute injury scenarios. The priority is to provide immediate passive immunity.
Choice B rationale
Administration of tetanus immune globulin provides immediate passive immunity. This is crucial to prevent tetanus infection since the client has not been immunized since infancy.
Choice C rationale
Inducing labor to avoid tetanus in the fetus is not a recommended action. The focus should be on providing immediate protection to the mother to prevent infection.
Choice D rationale
Administration of tetanus immune globulin after delivery delays necessary immediate protection. The risk of tetanus infection is immediate, so prompt administration is required.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale
Do not gain more than 25 pounds in pregnancy due to body image issues is incorrect. Gaining an appropriate amount of weight based on individual health and pregnancy needs is important, and it should not be restricted based on body image concerns.
Choice B rationale
Continue to take your prenatal vitamin every day is correct. Prenatal vitamins are essential in providing the necessary nutrients for both the mother and developing fetus, including folic acid, iron, and calcium.
Choice C rationale
Avoid alcohol, tobacco, and drugs is correct. These substances can have harmful effects on fetal development and should be avoided to ensure a healthy pregnancy.
Choice D rationale
Do not eat more than 12 ounces of low mercury fish each week is correct. While fish can be a good source of protein and omega-3 fatty acids, it's important to limit intake of fish that may contain higher levels of mercury to avoid potential harm to the fetus.
Choice E rationale
Increase caloric intake by 100-200 a day is correct. Pregnant teens need additional calories to support their own growth as well as that of the fetus, but the increase should be moderate and balanced with nutritional needs. .
Correct Answer is A
Explanation
Choice A rationale
Rh(D) immunoglobulin prevents the formation of Rh antibodies in Rh-negative mothers. This is crucial to prevent Rh sensitization, which can lead to hemolytic disease of the newborn in current and future pregnancies.
Choice B rationale
Rh(D) immunoglobulin does not prevent the formation of Rh antibodies in newborns who are Rh positive. Instead, it works by preventing the mother's immune system from recognizing Rh-positive fetal cells.
Choice C rationale
Rh(D) immunoglobulin does not destroy Rh antibodies in Rh-negative mothers. Its purpose is to prevent the formation of these antibodies in the first place.
Choice D rationale
Rh(D) immunoglobulin does not destroy Rh antibodies in newborns who are Rh positive. The newborn's immune system is not targeted by this immunoglobulin.
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