Nokea
A client's prenatal screening indicated that she has no immunity to rubella. She is now 10 weeks pregnant. The best time to immunize her is:
- A. In the immediate postpartum period
- B. After the first trimester
- C. At 28 weeks' gestation
- D. Within 72 hours postpartum
Correct Answer: A
Rationale: The rubella vaccine is made with attenuated virus and is given in the immediate postpartal period to prevent infection during pregnancy and subsequent adverse fetal and neonatal sequelae. Mothers are advised to prevent pregnancy for 3 months following immunization. Rubella infection during the second trimester may result in permanent hearing loss for the fetus. RhoGam is the drug generally administered at 28 weeks' gestation to Rh-negative women. It is contraindicated to administer rubella vaccine during pregnancy. RhoGam is the drug administered within 72 hours postpartum to Rh-negative women to prevent the development of antibodies to fetal cells.
You may also like to solve these questions
A 23-year-old college student seeks medical attention at the college infirmary for complaints of severe fatigue. Her skin is pale, and she reports exertional dyspnea. She is admitted to the hospital with possible aplastic anemia. Laboratory values reflect anemia, and the client is prepared for a bone marrow biopsy. She refuses to sign the biopsy consent and states, 'Can't you just get the doctor to give me a transfusion and let me go. This weekend begins spring break, and I have plans to go to Florida.' At this time the nurse's greatest concern is that:
- A. The client may contract an infection as a result of being exposed to large crowds at spring break
- B. The client does not grasp the full impact of her illness
- C. The client may require transfusion before leaving for spring break
- D. The causative agent be identified and treatment begun
Correct Answer: B
Rationale: The client could contract an infection, but at this point it is not the most pertinent issue. The client's statement indicates that she does not grasp the full impact of her illness. Further client education must be given, along with allowing her to express her feelings regarding her illness. The client may require a transfusion, but this is a temporary measure because the causative agent has not been identified. Her feelings regarding her illness must be addressed in order for care to continue. A bone marrow is done first to make a definitive diagnosis; then treatment may begin.
A 4 year old has an imaginary playmate, which concerns the mother. The nurse's best response would be:
- A. I understand your concern and will assist you with a referral.'
- B. Try not to worry because you will just upset your child.'
- C. Just ignore the behavior and it should disappear by age 8.'
- D. This is appropriate behavior for a preschooler and should not be a concern.'
Correct Answer: D
Rationale: This is normal for a preschooler, and a referral is not appropriate. Telling a parent not to worry is unhelpful. This response does not address the mother's concern. This response is incorrect. The behavior is normal and will usually disappear by the time the child enters school. This behavior is normal development for a preschooler.
A client with leukemia who has been receiving Trimetrexate (methotrexate) has an order for Wellcovorin (leucovorin). The rationale for administering Wellcovorin is to:
- A. Treat anemia caused by the methotrexate
- B. Create a synergistic effect that shortens treatment time
- C. Increase the number of circulating neutrophils
- D. Reverse drug toxicity and prevent tissue damage
Correct Answer: D
Rationale: Leucovorin (Wellcovorin) is a rescue therapy given after methotrexate to reverse its toxicity and protect healthy cells from damage particularly in bone marrow and mucosal tissues. It does not treat anemia enhance synergy or increase neutrophils.
A client diagnosed with bipolar disorder continues to be hyperactive and to lose weight. Which of the following nutritional interventions would be most therapeutic for him at this time?
- A. Small, frequent feedings of foods that can be carried
- B. Tube feedings with nutritional supplements
- C. Allowing him to eat when and what he wants
- D. Giving him a quiet place where he can sit down to eat meals
Correct Answer: A
Rationale: The manic client is unable to sit still long enough to eat an adequate meal. Small, frequent feedings with finger foods allow him to eat during periods of activity. This type of therapy should be implemented when other methods have been exhausted. The manic client should not be in control of his treatment plan. This type of client may forget to eat. The manic client is unable to sit down to eat full meals.
A client hospitalized with cirrhosis has developed abdominal ascites. The nurse should provide the client with snacks that provide additional:
- A. Sodium
- B. Potassium
- C. Protein
- D. Fat
Correct Answer: C
Rationale: Ascites in cirrhosis is linked to hypoalbuminemia; increasing protein intake helps restore albumin levels, reducing fluid accumulation.