A nurse is caring for a client during the second trimester of pregnancy.After reviewing the client's blood work, the nurse notes the client is rubella non-immune.
When should the client be offered the rubella immunization?
Advise the client it is safest to administer in the third trimester.
Advise the client it would be best to get the vaccine during her next attempt to get pregnant.
Advise the client it is best to receive the vaccine immediately to minimize risk to the fetus.
In postpartum, prior to being discharged from the hospital.
The Correct Answer is D
Choice A rationale
Administering the rubella vaccine during pregnancy, including the third trimester, is contraindicated due to the risk of live vaccine transmission to the fetus. It is not recommended at any stage of pregnancy.
Choice B rationale
Advising the client to get the vaccine during her next pregnancy attempt is partly correct but lacks the immediacy needed to ensure she is immune before the next pregnancy. The vaccine should be given postpartum.
Choice C rationale
Administering the vaccine immediately during pregnancy is contraindicated due to potential risks to the fetus. Rubella vaccines contain live virus, which can cause fetal harm if given during pregnancy.
Choice D rationale
It is safest to administer the rubella vaccine postpartum, prior to hospital discharge, to ensure the client has immunity before any future pregnancies. This timing prevents any risk to the current fetus and ensures future fetal protection. .
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Correct Answer is C
Explanation
Choice A rationale
Category 1 is a normal fetal heart rate pattern with no signs of fetal distress, which is not applicable in this case.
Choice B rationale
Category 2 represents an intermediate category with some concerns, but recurrent late decelerations and absent variability place this scenario in a higher risk category.
Choice C rationale
Category 3 indicates abnormal fetal heart rate patterns, including absent variability with recurrent late decelerations, which is associated with potential fetal hypoxia or acidemia and requires prompt intervention.
Choice D rationale
There is no Category 4 in fetal heart rate monitoring.
Correct Answer is C
Explanation
Choice A rationale
Irregular menses are not a direct risk factor for cervical cancer. While they can indicate hormonal imbalances, they are not strongly linked to cervical cancer risk.
Choice B rationale
Menopausal status and hormone replacement therapy (HRT) are more closely linked to breast cancer risks rather than cervical cancer. Cervical cancer is primarily associated with HPV infection.
Choice C rationale
Multiple sexual partners increase the risk of HPV infection, which is the primary cause of cervical cancer. HPV is a sexually transmitted infection that significantly raises the likelihood of developing cervical cancer.
Choice D rationale
A family history of breast cancer is more relevant to breast cancer risk rather than cervical cancer. Cervical cancer risk is more closely linked to HPV infection and sexual behavior.