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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?

A.

I need a second vaccination at my postpartum visit.

B.

I will need to use contraception for 3 months before considering pregnancy.

C.

I was given the vaccine because my baby is O-positive.

D.

I will be tested in 3 months to see if I have developed immunity.

Answer and Explanation

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 C

Explanation

Choice A rationale

Within 2 days after delivery is not the typical timeframe for breast milk to come in. Colostrum, the first milk, is produced immediately after birth, but mature milk usually comes in a few days later.

Choice B rationale

In about 10 days after delivery is too late for the onset of mature breast milk. Most women experience their milk coming in within the first week postpartum.

Choice C rationale

In 3 to 5 days after delivery is the correct response. This is the typical timeframe for the transition from colostrum to mature milk. During this period, the breasts may feel fuller and heavier as milk production increases.

Choice D rationale

In 6 to 8 days after delivery is later than the usual timeframe for breast milk to come in. While there can be some variation, most women experience their milk coming in within 3 to 5 days postpartum.

Correct Answer is A

Explanation

Choice A rationale

Completely emptying each breast at each feeding or using a pump helps prevent milk stasis, which can lead to mastitis. Ensuring the breasts are fully emptied reduces the risk of blocked ducts and infection.

Choice B rationale

Nursing on only the unaffected breast can lead to engorgement and worsening of mastitis in the affected breast. It is important to continue breastfeeding on both sides to maintain milk flow and prevent complications.

Choice C rationale

Wearing a tight-fitting bra can restrict milk flow and exacerbate mastitis. A well-fitting, supportive bra is recommended to avoid further complications.

Choice D rationale

Limiting the time the infant nurses on each breast can lead to incomplete emptying and increase the risk of mastitis. It is important to ensure the breasts are fully emptied to prevent infection.

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