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 negative.
The client is Rh negative and the newborn is Rh positive.
The client is Rh negative and the newborn is Rh negative.
The client is Rh positive and the newborn is Rh positive.
The Correct Answer is B
Choice A rationale:
If the client is Rh positive and the newborn is Rh negative, there is no indication for administering Rho(D) immune globulin. Rho(D) immune globulin is only given when the Rh-negative mother gives birth to an Rh-positive baby.
Choice B rationale:
This is the correct choice for administering Rho(D) immune globulin. When the mother is Rh negative and the newborn is Rh positive, there is a risk of Rh incompatibility. If the fetal blood enters the mother's circulation during delivery, her immune system may produce antibodies against Rh-positive blood cells, which can be harmful to future Rh-positive pregnancies. To prevent this, Rho(D) immune globulin is administered to the Rh-negative mother shortly after delivery.
Choice C rationale:
If both the mother and the newborn are Rh-negative, there is no risk of Rh incompatibility. Rho(D) immune globulin is not required in this situation.
Choice D rationale:
If both the mother and the newborn are Rh-positive, there is no risk of Rh incompatibility. Rho(D) immune globulin is not indicated in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Rh incompatibility is not relevant in this scenario. Rh incompatibility refers to a condition where the mother's blood is Rh-negative, and the baby's blood is Rh-positive, which can lead to hemolytic disease of the newborn. However, this condition is unrelated to the client's current presentation of heavy, red vaginal bleeding without contractions.
Choice B rationale:
Frequency and duration of contractions are not the primary concern in this situation. The client's main complaint is heavy vaginal bleeding without contractions, which indicates a potential issue with the placenta or other pregnancy-related problems.
Choice C rationale:
Fetal lung maturity is not the priority at this stage. The client is at 38 weeks of gestation, which is considered full term. Fetal lung maturity is typically assessed if there's a need for early delivery, which is not indicated in this scenario.
Choice D rationale:
The correct choice. The client is experiencing heavy, red vaginal bleeding, which may be a sign of placental abruption, where the placenta separates from the uterine wall prematurely. Determining the location of the placenta through an ultrasound can help identify if placental abruption is the cause of bleeding. Placental abruption can be a serious condition that requires immediate medical attention.
Correct Answer is B
Explanation
Choice A rationale:
If the client is Rh positive and the newborn is Rh negative, there is no indication for administering Rho(D) immune globulin. Rho(D) immune globulin is only given when the Rh-negative mother gives birth to an Rh-positive baby.
Choice B rationale:
This is the correct choice for administering Rho(D) immune globulin. When the mother is Rh negative and the newborn is Rh positive, there is a risk of Rh incompatibility. If the fetal blood enters the mother's circulation during delivery, her immune system may produce antibodies against Rh-positive blood cells, which can be harmful to future Rh-positive pregnancies. To prevent this, Rho(D) immune globulin is administered to the Rh-negative mother shortly after delivery.
Choice C rationale:
If both the mother and the newborn are Rh-negative, there is no risk of Rh incompatibility. Rho(D) immune globulin is not required in this situation.
Choice D rationale:
If both the mother and the newborn are Rh-positive, there is no risk of Rh incompatibility. Rho(D) immune globulin is not indicated in this case.
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