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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Choice A, fetal head compression, is not the correct answer in this case. Fetal head compression can cause early decelerations in the FHR, not variable decelerations. Early decelerations are often a result of the fetal head being compressed during contractions and are considered benign and expected during labor.

Choice B rationale:

The correct answer is choice B, which is umbilical cord compression. Variable decelerations of the fetal heart rate (FHR) can occur during labor due to various rationales, and umbilical cord compression is one of the common causes. When the umbilical cord gets compressed, it can briefly reduce or restrict the blood flow and oxygen supply to the fetus, leading to temporary decelerations in the FHR.

Choice C rationale:

Choice C, maternal fever, is also not the correct answer for variable decelerations in FHR. Maternal fever can be a sign of infection, and it may lead to other fetal heart rate abnormalities, such as tachycardia (an increased heart rate), but it is not specifically associated with variable decelerations.

Choice D rationale:

Choice D, polyhydramnios, is not the cause of variable decelerations in this scenario. Polyhydramnios refers to an excessive accumulation of amniotic fluid around the fetus. While it can have implications for pregnancy, it is not directly linked to variable decelerations of the FHR.

A. Calcium gluconate. B. Naloxone. C. Flumazenil. D. Protamine sulfate.

Correct Answer is A

Explanation

Choice A rationale :

The correct answer is A. Calcium gluconate. The nurse should administer calcium gluconate in this situation because the client's respiratory rate is 8/min, which indicates respiratory depression. Magnesium sulfate is known to cause respiratory depression as a side effect, and calcium gluconate is the antidote for magnesium sulfate toxicity. Calcium gluconate works by antagonizing the effects of magnesium on the neuromuscular junction and restoring normal respiratory function. Prompt administration of calcium gluconate can help reverse respiratory depression and prevent further complications.

Choice B rationale

Naloxone. Naloxone is not the correct choice in this scenario. Naloxone is an opioid antagonist and is used to reverse the effects of opioids in cases of opioid overdose. Since the client is receiving magnesium sulfate, which is not an opioid, naloxone would not be effective in reversing the respiratory depression caused by magnesium sulfate. Administering naloxone in this situation would not address the underlying cause and may not improve the client's condition.

Choice C rationale

Flumazenil. Flumazenil is not the correct choice in this situation. Flumazenil is a benzodiazepine antagonist and is used to reverse the effects of benzodiazepines in cases of benzodiazepine overdose. Since the client is not receiving benzodiazepines but rather magnesium sulfate, flumazenil would not be effective in treating the respiratory depression caused by magnesium sulfate. Using flumazenil in this context would not be appropriate and could potentially lead to adverse effects.

Choice D rationale

Protamine sulfate. Protamine sulfate is not the correct choice in this scenario. Protamine sulfate is an antidote for heparin overdose, not for magnesium sulfate toxicity. It works by neutralizing the effects of heparin and preventing further anticoagulation. Since the client's issue is respiratory depression caused by magnesium sulfate, administering protamine sulfate would not be helpful and would not address the primary problem.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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