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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C) Cephalhematoma:
A cephalhematoma is a collection of blood between the skull bone and its periosteum. It appears as a raised, bruised area on the scalp and is typically limited by suture lines. Unlike caput succedaneum, which typically resolves within a few days and crosses suture lines, a cephalhematoma does not cross suture lines and may take weeks to months to resolve.
A) Caput succedaneum:
Caput succedaneum is a localized swelling of the soft tissues of the scalp, usually resulting from pressure against the dilating cervix during labor. It typically crosses suture lines and resolves within a few days.
B) Pilonidal dimple:
A pilonidal dimple is a small pit or sinus in the sacrococcygeal area, not related to scalp findings.
D) Molding:
Molding refers to the shaping of the fetal head to adapt to the birth canal during labor and delivery. It is a temporary deformity and does not involve bruising or raised areas on the scalp.
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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