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 negative and the newborn is Rh positive.
The client is Rh positive 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 negative.
The Correct Answer is A
Choice A rationale:
When a pregnant client is Rh negative and the newborn is Rh positive, it can lead to Rh incompatibility issues. This occurs when fetal Rh-positive red blood cells enter the maternal circulation during pregnancy or childbirth, causing the mother's immune system to produce antibodies against Rh-positive blood cells. To prevent Rh sensitization, Rho(D) immune globulin is administered to Rh-negative pregnant clients at specific times during pregnancy and postpartum. This administration is essential to prevent hemolytic disease of the newborn in future pregnancies. The Rho(D) immune globulin prevents the mother's immune system from developing antibodies against Rh-positive blood cells, ensuring that the current pregnancy and future pregnancies remain safe. Therefore, choice A is the correct answer.
Choice B rationale:
If the client is Rh positive and the newborn is Rh positive, there is no need for Rho(D) immune globulin administration. Rh incompatibility issues only occur when the mother is Rh negative, and the newborn is Rh positive. Therefore, choice B is not the correct answer.
Choice C rationale:
When both the client and the newborn are Rh negative, there is no risk of Rh incompatibility, and therefore, Rho(D) immune globulin administration is unnecessary. This situation is not a reason to administer Rho(D) immune globulin. Choice C is not the correct answer.
Choice D 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 administration is not required in this scenario. Choice D is not the correct answer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
To calculate the amount of vitamin K (1 mg) to administer, you need to use the given concentration (1 mg/0.5 mL). This means that 1 mg is present in every 0.5 mL of the solution. To determine how many milliliters (mL) you should administer to get 1 mg, you can set up a proportion: 1 mg / X mL = 1 mg / 0.5 mL Cross-multiply and solve for X: X = (1 mg * 0.5 mL) / 1 mg X = 0.5 mL Therefore, the nurse should administer 0.5 mL, which can be rounded to 2.0 mL to the nearest tenth of a milliliter. Now, let's move on to the next question.
Correct Answer is D
Explanation
Choice A rationale:
The statement, "I will eat every 6 hours throughout the day," is not the best approach for a client with hyperemesis gravidarum. Eating at regular intervals may not be well-tolerated in this condition, as frequent nausea and vomiting can make it challenging to keep food down.
Choice B rationale:
The statement, "I will drink water with my meals," is generally a good practice during pregnancy to stay hydrated. However, for a client with hyperemesis gravidarum, it may be advisable to separate fluid intake from meals to minimize the risk of triggering nausea.
Choice C rationale:
The statement, "I will limit my protein intake," is not a recommended approach, especially for a pregnant client. Protein is essential for fetal development, and limiting protein intake may not provide adequate nutrition for the growing fetus.
Choice D rationale:
The statement, "I will eat crackers before I get out of bed in the morning," is a good strategy for managing morning sickness, which is common in pregnancy. Eating plain crackers before getting out of bed can help alleviate nausea and stabilize blood sugar levels.
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