A charge nurse is teaching a newly licensed nurse about Rho(D) immune globulin administration. Which of the following should the charge nurse include as an indication for the administration of Rho(D) immune globulin?
Hyperemesis gravidarum
Rh-positive blood test results
Prescription for an amniocentesis
Anemia
The Correct Answer is C
This is because a prescription for an amniocentesis is an indication for the administration of Rho(D) immune globulin (RhIG) to prevent RhD isoimmunization in mothers who are RhD negative¹². RhD isoimmunization is a condition where the mother's immune system produces antibodies against the RhD antigen on the baby's red blood cells, which can cause hemolytic disease of the newborn (HDN)¹². RhIG is a medication that contains antibodies against the RhD antigen, and it works by binding to and destroying any fetal red blood cells that may enter the maternal circulation, preventing the mother from making her own antibodies¹²³. RhIG is usually given to RhD negative mothers during pregnancy and after delivery if the baby is RhD positive¹².
Amniocentesis is a procedure where a needle is inserted into the uterus to obtain a sample of amniotic fluid, which contains fetal cells and other substances⁴. Amniocentesis can be done for various reasons, such as genetic testing, fetal lung maturity assessment, or infection diagnosis⁴. However, amniocentesis also carries a risk of causing bleeding or leakage of amniotic fluid, which can result in fetal-maternal hemorrhage (FMH), where fetal blood cells enter the maternal circulation⁴⁵. FMH can trigger RhD isoimmunization in RhD negative mothers, so they should receive RhIG within 72 hours of the procedure to prevent this complication⁵.
The other options are not correct because:
a) Hyperemesis gravidarum is not an indication for RhIG administration. Hyperemesis gravidarum is a condition where the mother experiences severe nausea and vomiting during pregnancy, which can cause dehydration, electrolyte imbalance, and weight loss. Hyperemesis gravidarum does not affect the blood type or compatibility of the mother and the baby, and does not increase the risk of RhD isoimmunization or HDN.
b) Rh-positive blood test results are not an indication for RhIG administration. Rh-positive blood test results mean that the mother has the RhD antigen on her red blood cells, and therefore she cannot develop antibodies against it¹². Rh-positive mothers do not need RhIG, as they are not at risk of RhD isoimmunization or HDN¹².
d) Anemia is not an indication for RhIG administration. Anemia is a condition where the mother has a low level of hemoglobin or red blood cells, which can cause fatigue, weakness, and shortness of breath. Anemia can have various causes, such as iron deficiency, bleeding, or infection. Anemia does not affect the blood type or compatibility of the mother and the baby, and does not increase the risk of RhD isoimmunization or HDN.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Using povidone-iodine on the site of a myelomeningocele is not recommended as it can be irritating to the tissue and might not be safe for use on open neural tissue. The focus should be on preventing infection through other means.
B. Administering broad-spectrum antibiotics is crucial as the cerebrospinal fluid (CSF) leak increases the risk of infection, such as meningitis. Antibiotics help protect the newborn from potentially serious infections until surgical repair can be performed.
C. Surgical closure of a myelomeningocele is typically done as soon as possible, often within 24-48 hours after birth, to minimize the risk of infection and further damage to the exposed spinal cord.
D. While monitoring temperature is important, rectal temperature measurement is not recommended for a newborn with a myelomeningocele due to the risk of causing further complications. Axillary temperature measurement would be safer and less invasive.
Correct Answer is A, B, D, C
Explanation
- Compressing the bulb syringe before placing it in the newborn's mouth or nose creates a vacuum that allows the suctioning of the mucus¹².
- Placing the bulb syringe in the newborn's mouth first helps clear the oral airway and prevent aspiration of mucus into the lungs¹². The nozzle of the bulb syringe should be gently inserted into the corner of the mouth, not the center, to avoid stimulating the gag reflex¹².
- Using the bulb syringe to suction the newborns nose helps clear the nasal airway and improve breathing¹². The nozzle of the bulb syringe should be gently inserted into one nostril at a time, and not too far, to avoid injuring the nasal mucosa¹².
- Assessing the newborn for reflex bradycardia helps monitor for any adverse effects of suctioning, such as a decrease in heart rate due to vagal stimulation¹³. Reflex bradycardia can cause hypoxia and acidosis in newborns, and may require oxygen administration or resuscitation³. The normal heart rate for a newborn is 120 to 160 beats per minute³.
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