Nokea
A nurse is providing teaching about immunizations to a client who is pregnant. Which of the following statements should the nurse include in the teaching?
- A. The immunization for varicella should be given at least 1 month prior to delivery.
- B. You can receive the rubella immunization during the third trimester of pregnancy.
- C. The hepatitis B immunization should not be obtained until after you finish breastfeeding.
- D. You can receive the immunization for influenza at any time during your pregnancy.
Correct Answer: D
Rationale: The influenza vaccine is safe and recommended during any trimester of pregnancy to protect both the mother and the baby.
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What is the recommended age for the first hepatitis B vaccine for a newborn?
- A. At birth
- B. Within 48 hours of birth
- C. Within 1 week of birth
- D. Within 1 month of birth
Correct Answer: B
Rationale: The correct answer is B: Within 48 hours of birth. This is recommended because newborns are most susceptible to hepatitis B infection during delivery. Administering the vaccine within 48 hours provides early protection. Choice A (At birth) is not specific enough and may delay vaccination. Choices C and D are too late and leave the newborn vulnerable for a longer period.
What is the function of the umbilical cord during pregnancy?
- A. To transport oxygen and nutrients from the mother to the fetus
- B. To remove waste products from the fetus
- C. To regulate fetal temperature
- D. All of the above
Correct Answer: A
Rationale: The correct answer is A. The umbilical cord functions to transport oxygen and nutrients from the mother to the fetus. This is crucial for the fetus's growth and development. B is incorrect because waste products are removed through the placenta, not the umbilical cord. C is incorrect as the umbilical cord does not regulate fetal temperature. Choice D is incorrect as it includes all options, but only A is accurate.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- A. Collect a urine specimen, Instruct the parent to feed the newborn, Place the Newborn under a phototherapy lamp, Admister penicilin IM
- B. Hypoglycemia, Congenital Syphilis,Kernicterus, Neonatal abstinence syndrome
- C. Balirubin Levels, Temperatures, Resipiratory Status, Environmental stimuli
Correct Answer:
Rationale:
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take?
- A. Administer aspirin for pain.
- B. Maintain the client on bed rest.
- C. Massage the affected leg every 12 hr.
- D. Apply cold compresses to the affected calf.
Correct Answer: B
Rationale: Maintaining the client on bed rest helps prevent the dislodgement of a thrombus, which could lead to a pulmonary embolism, a life-threatening complication.
A nurse is caring for a client who is receiving oxytocin via continuous IV infusion and is experiencing persistent late decelerations in the FHR. After discontinuing the infusion, which of the following actions should the nurse take?
- A. Instruct the client to bear down and push with contractions.
- B. Administer oxygen at 10 L/min via nonrebreather facemask.
- C. Place the client in a supine position.
- D. Initiate an amnioinfusion.
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen at 10 L/min via nonrebreather facemask. Late decelerations in FHR during oxytocin infusion indicate uteroplacental insufficiency. Administering oxygen helps improve oxygenation to the fetus, potentially alleviating the late decelerations. This action addresses the underlying cause and supports fetal oxygenation. In contrast, option A may increase intrauterine pressure, worsening fetal distress. Option C (supine position) can further compromise placental perfusion. Option D (amnioinfusion) is used for variable decelerations, not late decelerations.