A nurse is planning to administer Rh(D) immune globulin to a client who is postpartum.
Which of the following actions should the nurse take?
Verify that the newborn is Rh-negative.
Verify that the client’s Coombs test is positive.
Administer the medication within 72 hours after birth.
Administer the medication into the client’s abdomen.
The Correct Answer is C
Choice A rationale
Verifying that the newborn is Rh-negative is not necessary for administering Rh(D) immune globulin. The medication is given to Rh-negative mothers to prevent Rh sensitization, regardless of the newborn’s Rh status.
Choice B rationale
A positive Coombs test indicates that the mother has already been sensitized to Rh-positive blood cells, making Rh(D) immune globulin ineffective in preventing sensitization.
Choice C rationale
Administering Rh(D) immune globulin within 72 hours after birth is crucial to prevent Rh sensitization in future pregnancies. This timing ensures that the mother’s immune system does not produce antibodies against Rh-positive blood cells.
Choice D rationale
Rh(D) immune globulin is typically administered intramuscularly, not into the abdomen. The preferred sites are the deltoid muscle or the anterolateral aspect of the thigh.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Administering NSAIDs every 4 to 6 hours is not a primary measure to prevent thrombophlebitis. NSAIDs are used for pain relief and inflammation reduction, but they do not directly prevent blood clots.
Choice B rationale
Applying elastic stockings before the client gets out of bed can help prevent blood clots by promoting blood flow in the legs. However, this measure alone is not sufficient to prevent thrombophlebitis.
Choice C rationale
Ambulation, or walking, is one of the most effective measures to prevent thrombophlebitis. It promotes circulation and prevents blood from pooling in the legs, reducing the risk of clot formation.
Choice D rationale
Applying warm, moist packs to the client’s lower legs can help relieve pain and inflammation but does not directly prevent thrombophlebitis. This measure is more supportive rather than preventive.
Correct Answer is []
Explanation
Based on the provided information,
Most Likely Potential Condition
- A. Placenta previa
Actions to Take
- A. Reinforce with the client to maintain bed rest
- C. Insert a large bore intravenous catheter
Parameters to Monitor
- B. Fetal well-being
- D. Vaginal bleeding
Explanation of Other Conditions
- Abruptio placentae:
- Reasoning: This condition typically presents with painful bleeding and a tender, rigid abdomen, which is not consistent with the client’s symptoms of painless, bright red bleeding and a soft, non-tender abdomen.
- Preterm labor:
- Reasoning: The client shows no signs of labor, such as uterine contractions or cervical dilation. The bleeding is also bright red and painless, which is more indicative of placenta previa.
- Cervical insufficiency:
- Reasoning: This condition usually involves painless cervical dilation and effacement without contractions, leading to preterm birth. The client’s cervix is not dilated, and there are no signs of labor, making this condition less likely.
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