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 D

Explanation

Choice A rationale

Calling the healthcare provider delays immediate intervention needed to alleviate the client's symptoms of dizziness and nausea due to supine hypotensive syndrome. Quick repositioning is crucial to improve venous return and alleviate the symptoms.

Choice B rationale

Elevating the head of the bed will not relieve the pressure on the inferior vena cava caused by the supine position. This intervention does not address the underlying cause of the client's symptoms.

Choice C rationale

Encouraging deep breathing is unlikely to resolve the symptoms of supine hypotensive syndrome, which is caused by the compression of the vena cava by the gravid uterus when lying supine. This intervention does not address the physiological cause.

Choice D rationale

Turning her to her side relieves the pressure on the inferior vena cava, improving venous return and increasing blood pressure. This is the correct initial action to address the symptoms of supine hypotensive syndrome.

Correct Answer is ["July 27"]

Explanation

Step 1 is to identify the first day of the last menstrual period (LMP), which is October 20.

Step 2 is to count back 3 months from October 20, resulting in July 20.

Step 3 is to add 1 year to July 20, resulting in July 20 of the following year.

Step 4 is to add 7 days to July 20, resulting in July 27.

Final calculated answer: July 27 of the following year.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a woman in early labor.While positioning her for a vaginal exam, she complains of dizziness and nausea and appears pale.Her blood pressure has dropped slightly.What is the appropriate initial nursing action?

Correct Answer is D

Explanation

A pregnant client tells the nurse that her LMP was 3 months ago and began on October 20. Using Naegele's rule, calculate the client's estimated date of delivery. Answer format: "October 20"

Correct Answer is ["July 27"]

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?