A nurse is caring for a client who is postpartum and has a prescription for Rho (D) Immunoglobulin. The nurse should verify which of the following prior to administration?

Client is Rh negative and the newborn is Rh positive.

Client is Rh positive and the newborn is Rh negative.

Client is Rh positive and the newborn is Rh positive.

Client is Rh negative and the newborn is Rh negative.

Answer and Explanation

The Correct Answer is A

A) Client is Rh negative and the newborn is Rh positive:

This is the correct response. Rho (D) Immunoglobulin, also known as RhoGAM, is administered to Rh-negative mothers who have given birth to Rh-positive infants. This medication helps prevent the mother's immune system from producing antibodies against Rh-positive blood cells, which could lead to hemolytic disease of the newborn in subsequent pregnancies. Administering RhoGAM in this scenario helps prevent sensitization of the mother's immune system to Rh-positive blood cells.

B) Client is Rh positive and the newborn is Rh negative:

Administering RhoGAM to an Rh-positive mother with an Rh-negative newborn would not be necessary because there is no risk of Rh incompatibility in this situation.

C) Client is Rh positive and the newborn is Rh positive:

Administering RhoGAM to an Rh-positive mother with an Rh-positive newborn would not be necessary because the mother and newborn share the same Rh factor, so there is no risk of Rh incompatibility.

D) Client is Rh negative and the newborn is Rh negative:

Administering RhoGAM to an Rh-negative mother with an Rh-negative newborn would not be necessary because there is no risk of Rh incompatibility in this situation.

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Correct Answer is D

Explanation

A) Hypothermia:

Hypothermia is a concern for newborns, particularly following delivery, as they are susceptible to heat loss due to their large surface area and limited ability to regulate body temperature. However, assessing for respiratory distress takes precedence over hypothermia assessment immediately after delivery.

B) Accidental lacerations:

While accidental lacerations can occur during cesarean delivery, they are not typically the primary concern immediately after delivery. Assessing for respiratory distress and ensuring the newborn's stability are the priority.

C) Acrocyanosis:

Acrocyanosis, the bluish discoloration of the extremities, is a common finding in newborns and is often benign. While it should be assessed and documented, it is not typically a priority over assessing for respiratory distress, especially in the immediate post-delivery period.

D) Respiratory distress:

Assessing for respiratory distress is the priority immediately following a scheduled cesarean delivery. Newborns born via cesarean section are at increased risk of respiratory distress due to delayed clearance of lung fluid, reduced catecholamine surge, and potential complications associated with maternal anesthesia. Signs of respiratory distress in a newborn may include cyanosis, grunting, nasal flaring, and chest retractions. Prompt recognition and intervention for respiratory distress are essential to prevent complications and ensure adequate oxygenation and ventilation.

A. The client is immune to the rubella virus. B. The client requires a rubella vaccination at this time. C. The client requires a rubella immunization following delivery. D. The client is not experiencing a rubella infection at this time.

Correct Answer is C

Explanation

A) The client is immune to the rubella virus:

A negative rubella titer indicates that the client is not immune to the rubella virus. Therefore, this interpretation is incorrect.

B) The client requires a rubella vaccination at this time:

A negative rubella titer indicates susceptibility to rubella and the need for vaccination. However, administering a live virus vaccine like rubella during pregnancy is contraindicated due to the risk of fetal harm. Therefore, this interpretation is incorrect.

C) The client requires a rubella immunization following delivery:

A negative rubella titer during pregnancy indicates susceptibility to rubella. After delivery, the client should receive a rubella immunization to prevent rubella infection in future pregnancies. Rubella vaccination is safe postpartum and helps protect the mother and future pregnancies. Therefore, this interpretation is correct.

D) The client is not experiencing a rubella infection at this time:

A rubella titer measures the level of antibodies to the rubella virus, not the presence of an active infection. A negative rubella titer indicates the absence of immunity to rubella, not the absence of an active infection. Therefore, this interpretation is incorrect.

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A nurse is caring for a client who is postpartum and has a prescription for Rho (D) Immunoglobulin. The nurse should verify which of the following prior to administration?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse's priority?

Correct Answer is D

Explanation

A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data?

Correct Answer is C

Explanation

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