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:
The client's statement, "I need to schedule the test when the baby is usually active,”. is accurate and demonstrates a good understanding of the nonstress test (NST). The NST is typically performed to assess the baby's heart rate and movements when they are active, which provides better insights into the baby's well-being.
Choice B rationale:
The client's statement, "The baby's heart rate will be monitored during the test,”. is correct and indicates a solid grasp of the purpose of the NST. During the test, the baby's heart rate is continuously monitored to assess their overall well-being and any signs of distress.
Choice C rationale:
This is the correct answer. The client's statement, "I will have to lie on my back during the test,”. indicates a need for further teaching. In an NST, pregnant individuals are usually asked to lie on their left side, not on their back. The left lateral position enhances blood flow to the placenta and the baby, making it the preferred position for this test.
Choice D rationale:
The client's statement, "I will be able to go to the bathroom during the test as necessary,”. is accurate and demonstrates a good understanding of the NST procedure. Unlike some other prenatal tests, NST allows pregnant individuals to change positions, including using the bathroom if needed, to ensure their comfort during the monitoring process.
Correct Answer is B
Explanation
Choice A rationale:
Abdominal pain with minimal red vaginal bleeding may not be as concerning as other options. While it could be a sign of placenta previa, it is not as specific or significant as the finding in Choice B.
Choice B rationale:
A large amount of bright red vaginal bleeding without pain is a significant finding that is highly suggestive of placenta previa. Placenta previa occurs when the placenta partially or completely covers the cervix, and vaginal bleeding is a common symptom. The bright red colour indicates active bleeding, and the absence of pain is noteworthy as placenta previa bleeding is typically painless.
Choice C rationale:
Severe abdominal pain with increasing fundal height is not a typical sign of placenta previa. While abdominal pain can be associated with various pregnancy complications, it is not a specific finding for this condition.
Choice D rationale:
Intermittent abdominal pain following the passage of bloody mucus could be related to other issues, such as preterm labor or cervical changes. While bleeding may be present in placenta previa, the pain and passage of mucus are not characteristic features of this condition.
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