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 D
Explanation
he nurse should document the client's present gravidity (G) as 4.
Here's the breakdown:
- G stands for Gravidity, which is the total number of pregnancies a woman has had, regardless of their outcome.
- The client has had:
- 1 pregnancy terminated by elective abortion
- 1 pregnancy resulting in the birth of twins (counted as one pregnancy)
- 1 spontaneous abortion
- 1 current pregnancy (at 28 weeks)
Therefore, the total number of pregnancies is 4.
Correct Answer is D
Explanation
The normal sequence of postpartum vaginal discharge, known as lochia, follows this order:
D. Lochia rubra, lochia serosa, lochia alba.
Here's a quick breakdown:
-
Lochia rubra (Days 1–4): Bright red discharge with blood, mucus, and tissue.
-
Lochia serosa (Days 4–10): Pinkish or brownish discharge as bleeding slows.
-
Lochia alba (Days 10–6 weeks): Yellowish-white discharge as the body completes healing.
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