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 C
Explanation
Choice A rationale:
A fetal heart rate of 100/min for a 10-minute period is considered within the normal range. The normal fetal heart rate can range from 110 to 160 beats per minute, and a rate of 100 is not concerning.
Choice B rationale:
The resting period of a contraction refers to the time between contractions when the uterus is relaxed. A resting period of 35 seconds is also considered normal. In labor, the resting period between contractions allows the placenta to receive oxygen and nutrients, and 35 seconds is a rationaleable duration.
Choice C rationale:
A contraction lasting 85 seconds is abnormal and should be reported to the provider. Normally, contractions last around 60-90 seconds, but an 85-second contraction may indicate uterine hyperactivity or other issues that could potentially affect the well-being of both the mother and the baby.
Choice D rationale:
Having four contractions in a 10-minute period is considered normal during labor. In fact, an average pattern includes 3-5 contractions within a 10-minute window, so this finding is not a cause for concern.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale:
The nurse should report the blood pressure findings to the provider because there is a significant increase in both systolic and diastolic blood pressure. At 0900, the blood pressure was 156/90 mm Hg, and at 1000, it increased to 160/96 mm Hg. This significant elevation in blood pressure can be a cause for concern as it may indicate the development of gestational hypertension or preeclampsia, which can be dangerous for both the client and the fetus.
Choice B rationale:
Cerebral manifestations are not mentioned in the nurse's notes or vital signs and are not relevant to the given scenario. Therefore, this choice is not applicable in this case.
Choice C rationale:
The nurse should report the fetal heart rate findings to the provider because it is not included in the vital signs section of the nurse's notes. Monitoring the fetal heart rate is essential to ensure the well-being of the fetus, and any abnormalities or changes in the fetal heart rate should be promptly reported to the healthcare provider for further evaluation.
Choice D rationale:
The nurse should report the respiratory rate findings to the provider. Although the respiratory rate seems to be within the normal range (22/min at 0900 and 21/min at 1000), it is a vital sign that should be closely monitored in pregnant clients. Any sudden changes or abnormalities in the respiratory rate may indicate respiratory distress or other health issues that need medical attention. Choices E and F rationale: Deep tendon reflexes and gastrointestinal assessment findings are not mentioned in the nurse's notes or vital signs. These options are not applicable in this scenario and do not require reporting to the provider.
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