Nokea
A female client comes for her second prenatal visit. The nurse-midwife tells her, 'Your blood tests reveal that you do not show immunity to the German measles.' Which notation will the nurse include in her plan of care for the client? 'Will need . . .
- A. Rh-immune globulin at the next visit'
- B. Rh-immune globulin within 3 days of delivery'
- C. Rubella vaccine at the next visit'
- D. Rubella vaccine after delivery on the day of discharge'
Correct Answer: D
Rationale: Rh immune globulin is given to Rh-negative mothers to prevent the maternal Rh immune response. Rh immune globulin is given to Rh-negative mothers to prevent the maternal Rh immune response. The rubella vaccine is not given during pregnancy because of its teratogenicity. Nonimmune mothers are vaccinated early in the postpartum period to prevent future infection with the rubella virus.
You may also like to solve these questions
A child is admitted with suspected epiglottitis. Which action is not a part of the nursing care?
- A. Checking the vital signs
- B. Assessing the throat with a tongue blade
- C. Administering oxygen as needed
- D. Administering IV antibiotics
Correct Answer: B
Rationale: Assessing the throat with a tongue blade is contraindicated in suspected epiglottitis as it may trigger airway obstruction. Vital signs oxygen and antibiotics are appropriate interventions.
Before administering a client's morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to:
- A. Record the pulse rate and administer the medication
- B. Administer the medication and monitor the heart rate
- C. Withhold the medication and notify the doctor
- D. Withhold the medication until the heart rate increases
Correct Answer: C
Rationale: A pulse rate below 60 bpm indicates bradycardia, a contraindication for digoxin due to the risk of worsening heart block. The nurse should withhold the dose and notify the physician.
The physician has ordered DDAVP (desmopressin acetate) for a client with diabetes insipidus. Which finding indicates that the medication is having its intended effect?
- A. The client's appetite has improved.
- B. The client's morning blood sugar was 120 mg/dL.
- C. The client's urinary output has decreased.
- D. The client's activity level has increased.
Correct Answer: C
Rationale: DDAVP reduces excessive urination in diabetes insipidus by mimicking antidiuretic hormone, decreasing urinary output. Appetite, blood sugar, and activity are not directly affected.
The nurse is caring for a client in labor. The fetal monitor shows early decelerations. The nurse should:
- A. Notify the physician immediately
- B. Reposition the client to her left side
- C. Continue to monitor the fetal heart rate
- D. Administer oxygen at 8-10 liters per minute
Correct Answer: C
Rationale: Early decelerations are benign caused by fetal head compression during contractions and do not indicate fetal distress. Continuing to monitor the fetal heart rate is appropriate. Repositioning oxygen or notifying the physician are unnecessary unless other abnormalities occur.
The pediatrician has diagnosed tinea capitis in an 8-year-old girl and has placed her on oral griseofulvin. The nurse should emphasize which of these instructions to the mother and/or child?
- A. Administer oral griseofulvin on an empty stomach for best results.
- B. Discontinue drug therapy if food tastes funny.
- C. May discontinue medication when the child experiences symptomatic relief.
- D. Observe for headaches, dizziness, and anorexia.
Correct Answer: D
Rationale: Giving the drug with or after meals may allay gastrointestinal discomfort. Giving the drug with a fatty meal (ice cream or milk) increases absorption rate. Griseofulvin may alter taste sensations and thereby decrease the appetite. Monitoring of food intake is important, and inadequate nutrient intake should be reported to the physician. The child may experience symptomatic relief after 48-96 hours of therapy. It is important to stress continuing the drug therapy to prevent relapse (usually about 6 weeks). The incidence of side effects is low; however, headaches are common. Nausea, vomiting, diarrhea, and anorexia may occur. Dizziness, although uncommon, should be reported to the physician.