A nurse is caring for a client who is postpartum.
Which of the following findings is an indication for the nurse to administer Rho(D) immune globulin?

The client is Rh positive and the newborn is Rh positive.

The client is Rh positive and the newborn is Rh negative.

The client is Rh negative and the newborn is Rh negative.

The client is Rh negative and the newborn is Rh positive.

Answer and Explanation

The Correct Answer is D

Choice A rationale

If both the client and the newborn are Rh positive, there is no risk of Rh incompatibility, and Rho(D) immune globulin is not needed.

Choice B rationale

If the client is Rh positive and the newborn is Rh negative, there is no risk of Rh incompatibility, and Rho(D) immune globulin is not needed.

Choice C rationale

If both the client and the newborn are Rh negative, there is no risk of Rh incompatibility, and Rho(D) immune globulin is not needed.

Choice D rationale

If the client is Rh negative and the newborn is Rh positive, there is a risk of Rh incompatibility, and Rho(D) immune globulin is needed to prevent the development of Rh sensitization in future pregnancies. .

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Correct Answer is D

Explanation

Choice A rationale

A hymenal tag and white discharge on the genitalia are normal findings in newborn females, often due to maternal hormone exposure.

Choice B rationale

Edema on the scalp that crosses suture lines, known as caput succedaneum, is common and typically resolves on its own without intervention.

Choice C rationale

A heart murmur in a newborn can be normal, as many murmurs are benign and resolve as the newborn's circulation adjusts post-birth.

Choice D rationale

A large, deep sacral dimple above the gluteal cleft can be an indication of underlying spinal abnormalities, such as spina bifida, and requires further evaluation.

A. History of cocaine use. B. History of pelvic inflammatory disease (PID). C. History of three previous cesarean births. D. History of hypertension.

Correct Answer is B

Explanation

Choice A rationale

History of cocaine use increases the risk for placental abruption but is not a direct risk factor for ectopic pregnancy.

Choice B rationale

History of pelvic inflammatory disease (PID) is a significant risk factor for ectopic pregnancy due to the damage and scarring it can cause to the fallopian tubes, leading to implantation outside the uterus.

Choice C rationale

History of three previous cesarean births increases the risk of uterine rupture or placenta previa but not specifically ectopic pregnancy.

Choice D rationale

History of hypertension is not directly related to the risk of ectopic pregnancy; it is more associated with complications like preeclampsia and gestational hypertension.

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A nurse is caring for a client who is postpartum. Which of the following findings is an indication for the nurse to administer Rho(D) immune globulin?

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A nurse is caring for a client who is postpartum.
Which of the following findings is an indication for the nurse to administer Rho(D) immune globulin?