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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

Intrauterine growth restriction (IUGR) is a significant risk for newborns of mothers who smoke. Smoking affects placental blood flow, reducing the supply of oxygen and nutrients to the fetus, leading to poor growth.

Choice B rationale

Smoking is not a direct cause of gestational diabetes. Gestational diabetes is primarily related to hormonal changes in pregnancy that affect insulin regulation.

Choice C rationale

Congenital heart defects are not directly linked to smoking. They are usually caused by genetic and environmental factors during early fetal development, not smoking specifically.

Choice D rationale

Vision loss is not directly associated with maternal smoking. Smoking affects fetal growth and development, but vision loss is not a common outcome.

A. This is a possible sign of pregnancy. B. This is a positive sign of pregnancy. C. This is a presumptive sign of pregnancy. D. This is a probable sign of pregnancy.

Correct Answer is B

Explanation

Choice A rationale

A possible sign of pregnancy includes symptoms that are suggestive but not definitive, such as amenorrhea (absence of menstruation) or fatigue. These signs can have multiple causes and are not conclusive proof of pregnancy.

Choice B rationale

A positive sign of pregnancy includes objective evidence like fetal movement felt by the examiner, fetal heart sounds detected, or visualization of the fetus on ultrasound. These signs provide direct confirmation of pregnancy.

Choice C rationale

Presumptive signs of pregnancy are subjective experiences reported by the patient, such as nausea, breast tenderness, or quickening (feeling fetal movement). These signs are not confirmatory as they can occur in other conditions.

Choice D rationale

Probable signs of pregnancy include objective findings observed by a healthcare provider, such as uterine enlargement, but they are not definitive as they can also be caused by conditions like fibroids.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is speaking with a client who is 6 weeks' gestation.The client tells the nurse that she smokes one pack per day, but is trying to quit.The nurse should explain that newborns born to women who smoke are at risk for:

Correct Answer is A

Explanation

A nurse caring for a client in the prenatal clinic states that the patient is clearly pregnant because both the mother and examiner are able to feel the baby move.Which of the following signs of pregnancy is occurring?

Correct Answer is B

Explanation

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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?