Rationalization of Questions

#42. A Nurse is reviewing the results of the rubella screening (titer) with a pregnant 24 year old
client. The test results are positive, and the mother asks if it is safe for her toddler to receive the
vaccine. The appropriate nursing response is:

a. “You are still susceptible to rubella, so your toddler should receive the vaccine”
b. “Most children do not receive the vaccine until they are 5 years of age”
c. “it is not advised for children of pregnant women to be vaccinated during the
mother’s pregnancy”
d. “Your titer supports your immunity to rubella, and it is safe for your toddler to receive
the vaccine at the time”

Answer: D

Titer is the test for the presence of certain antibodies which would indicate if a patient
has bacteria or disease. However, the first dose of MMR vaccine is given at 12 through 15
months of age, and the second dose at 4 through 6 years of age.

Option A: The client is already positive in her test for rubella, so susceptibility does not apply. A
toddler is more susceptible to this disease therefore the need for vaccine is profound.

Option B: Children who has complete vaccine get first dose at the first year after born and last
dose at age of 5.

Option C: Children who get vaccinated at the right time has less possibilities to contract
diseases. Pregnant women who get vaccine may have fatal effect on the fetus.

#86. A non-stress test is performed on a client, and the results are documented in the chart. The
results are documented as “two or more fetal heart rate (FHR) accelerations of the 15 beats per
minute, lasting 15 seconds in association with fetal movement.” The nurse interprets these
findings as:

a. A reactive non-stress test

b. A nonreactive non-stress test
c. Unclear for accurate interpretations
d. Unsatisfactory

Answer: B

Is classified as nonreactive which does not meet the normal criteria. Most fetuses have
spontaneous accelerations at various points throughout the labor and delivery process. Doctor
may try to induce accelerations to the baby if they don’t see accelerations.

Option A: Reactive indicate a good sign for the well-being of fetus.

Option C: Unclear for accurate interpretations and unsatisfactory does not apply to fetal heart
monitoring.