A nurse is reinforcing postpartum discharge teaching to a client who had no immunity to varicella and was given the varicella vaccine.Which of the following statements by the client indicates understanding?
I need a second vaccination at my postpartum visit.
I will need to use contraception for 3 months before considering pregnancy.
I was given the vaccine because my baby is O-positive.
I will be tested in 3 months to see if I have developed immunity.
The Correct Answer is A
Choice A rationale
The client needs a second varicella vaccination at her postpartum visit to ensure full immunity. The initial dose provides partial immunity, and the second dose completes the vaccination series.
Choice B rationale
The client needs to use contraception for 1 month, not 3 months, before considering pregnancy after receiving the varicella vaccine. This is to prevent potential harm to a developing fetus.
Choice C rationale
The varicella vaccine is not given based on the baby’s blood type. It is administered to protect the client from varicella infection.
Choice D rationale
There is no need for testing to see if the client has developed immunity after receiving the varicella vaccine. The second dose is given to ensure full immunity.
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Correct Answer is B
Explanation
Choice B rationale
A heart rate of 110/min is a sign of tachycardia, which can indicate a postpartum complication such as infection, hemorrhage, or other underlying conditions. Tachycardia requires immediate assessment and intervention.
Choice A rationale
Chills shortly following delivery can be a normal response to the body’s adjustment after childbirth and do not necessarily indicate a complication.
Choice C rationale
Urinary output of 3,000 mL/12 hr is high but can be a normal part of postpartum diuresis as the body eliminates excess fluid accumulated during pregnancy.
Choice D rationale
The fundus at the umbilicus level is a normal finding in the immediate postpartum period and does not indicate a complication.
Correct Answer is B
Explanation
Choice A rationale
Massaging the area is not recommended as it can dislodge a clot and cause it to travel to the lungs, leading to a pulmonary embolism. This can be life-threatening and should be avoided.
Choice B rationale
Elevating the leg helps to reduce swelling and pain by promoting venous return. This is a standard intervention for managing symptoms of deep vein thrombosis (DVT) and helps prevent further complications.
Choice C rationale
Applying cold compresses is not effective for DVT. Cold compresses are generally used to reduce inflammation and pain in acute injuries, but they do not address the underlying issue of a blood clot.
Choice D rationale
Flexing the knee while resting can increase the risk of clot dislodgement and is not recommended. Keeping the leg straight and elevated is a safer approach to managing DVT symptoms.