A client is in the first trimester of pregnancy and lacks immunity to rubella. When should the client receive rubella immunization?

Correct Answer: A

Rationale: The correct answer is A. Rubella immunization should be given shortly after giving birth to prevent any potential harm to the fetus during pregnancy. Immunization during pregnancy is contraindicated to avoid any risk of harm to the developing baby. Option B is incorrect as immunization in the third trimester can still pose a risk to the fetus. Option C is incorrect as immediate immunization during pregnancy is not recommended. Option D is incorrect as waiting until the next attempt to get pregnant does not protect the current fetus.

Correct Answer: B

Rationale: The correct answer is B: Document this as an expected finding. A heart rate of 130/min in a newborn is within the normal range (120-160/min). The nurse should document this as an expected finding because it indicates a healthy heart rate for a newborn. There is no immediate need for intervention or further assessment as the heart rate falls within the normal range for a newborn. Asking another nurse to verify the heart rate (choice A) is unnecessary as it is within the normal range. Calling the provider to further assess the newborn (choice C) is not needed since the heart rate is normal. Preparing the newborn for transport to the NICU (choice D) is not indicated as the heart rate is within the normal range.

Correct Answer: A

Rationale: The correct answer is A: Palpate the client's uterine fundus. Palpating the uterine fundus is crucial to assess for uterine atony, a common cause of postpartum hemorrhage. If the fundus is boggy or deviated, it indicates uterine atony and immediate interventions are needed. B: Assisting the client to a bedpan to urinate is important, but addressing the potential cause of excessive bleeding takes precedence. C: Administering oxytocic medication may be necessary to help stimulate uterine contractions, but assessing the fundus comes first to determine the underlying cause of bleeding. D: Increasing fluid intake is not the priority in this situation. Palpating the fundus and addressing potential hemorrhage are the immediate concerns.

Correct Answer: D

Rationale: The correct answer is D, Deep tendon reflexes of +1. In preeclampsia, deep tendon reflexes are typically hyperactive, not diminished (+1). This indicates hyporeflexia, which is inconsistent with preeclampsia. A is consistent with preeclampsia, as mild edema is common. B is also consistent, as proteinuria is a hallmark sign. C is consistent, as elevated blood pressure is a key feature. Therefore, D is the only choice that does not align with the expected findings in preeclampsia.

Correct Answer: D

Rationale: The correct sequence of maternal changes when planning to become pregnant is A) Amenorrhea, C) Goodell's sign, D) Quickening, and B) Lightening. Amenorrhea is the absence of menstruation, indicating possible pregnancy. Goodell's sign is the softening of the cervix and vagina. Quickening is the first fetal movements felt by the mother. Lightening occurs as the baby drops lower into the pelvis. This sequence reflects the chronological order of physiological changes during pregnancy. Choices A, B, and C do not follow the correct sequence of maternal changes as outlined in pregnancy progression.

Correct Answer: C

Rationale: Rationale: Option C, having the client pant during the next contractions, is the correct answer. At 7 cm dilation with a sudden urge to push, it indicates possible fetal descent. Panting can help prevent rapid descent and reducing the risk of cervical edema or injury. It allows time for the cervix to dilate fully before pushing, preventing premature pushing and potential complications. Option A is not a priority at this stage. Option B is incorrect as observing for crowning might lead to premature pushing. Option D is not necessary as voiding is not the priority right now.

Correct Answer: D

Rationale: The correct answer is D: Frank breech. In a frank breech position, the buttocks of the fetus are presenting first, which is why the fetal heart tones can be heard above the umbilicus at midline. In this position, the feet are near the head, causing the buttocks to be the presenting part. Choices A, B, and C are incorrect because in a cephalic position, the head would be presenting, in a transverse position, the baby would be lying sideways, and in a posterior position, the baby's back would be against the mother's back.

Correct Answer: D

Rationale: The correct answer is D: Obtain a 30-minute electronic fetal monitoring (EFM) strip prior to induction. This is important to assess the fetal well-being and baseline status before initiating epidural analgesia. It helps in detecting any fetal distress or abnormalities that may be exacerbated by the epidural. A: Having the client sit upright with legs crossed is not recommended as it may interfere with the procedure and comfort of the client. B: Administering a 500 mL bolus of lactated Ringer's solution is not directly related to preparing for epidural analgesia. C: Informing the client about the duration of anesthetic effect is important, but ensuring fetal well-being through EFM monitoring is a priority before the procedure.

Correct Answer: A

Rationale: The correct answer is A: Painless red vaginal bleeding. This finding supports the diagnosis of placenta previa due to the characteristic symptom of painless bleeding in the third trimester. Placenta previa occurs when the placenta partially or completely covers the cervix, leading to bleeding as the cervix begins to dilate. The other choices are incorrect because increasing abdominal pain with a non-relaxed uterus (B) may indicate placental abruption, abdominal pain with scant red vaginal bleeding (C) is not typical of placenta previa, and intermittent abdominal pain following the passage of bloody mucus (D) is more suggestive of preterm labor or bloody show.