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.
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. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Rhythmic respirations indicate the client is using controlled breathing techniques to manage labor pain, which demonstrates effective coping. This method helps maintain oxygen levels and can reduce the perception of pain through focused breathing.
Choice B rationale
Crying during labor may indicate emotional distress or pain, suggesting the client might be struggling to cope effectively with labor. While it is a natural response, it is not typically associated with controlled coping mechanisms.
Choice C rationale
Lack of concentration can indicate that the client is overwhelmed by pain or anxiety, which may hinder her ability to use coping strategies effectively. It suggests she might be struggling to manage her labor experience.
Choice D rationale
Perspiration is a common physiological response to the exertion and stress of labor, but it does not specifically indicate how well the client is coping with labor pain or stress. It is a normal part of the labor process but not a clear sign of effective coping.
Correct Answer is C
Explanation
Choice A rationale
Obtaining a set of vital signs is important but not the first action. Assessing responsiveness and activating emergency response takes precedence to ensure prompt intervention.
Choice B rationale
Assessing vaginal bleeding is necessary, but it should follow immediate life-saving actions like calling the rapid response team.
Choice C rationale
Calling the rapid response team should be the first action as it mobilizes a team of healthcare professionals to provide immediate advanced care, which is crucial in an unresponsive patient.
Choice D rationale
Notifying the provider is essential, but it should be done after the rapid response team is activated to ensure timely intervention.
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