A nurse is teaching a client who is Rh negative about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?
"I will receive this medication if my baby is Rh-negative."
"I will receive this medication when I am in labor."
"I will need a second dose of this medication when my baby is 6 weeks old."
"I will need this medication if I have an amniocentesis."
The Correct Answer is D
Choice A Reason:
"I will receive this medication if my baby is Rh-negative." This statement does not record understanding of the teaching. The purpose of Rho(D) immune globulin is to prevent sensitization of an Rh-negative mother to Rh-positive fetal blood. If the baby is Rh-negative, there is no need for Rho(D) immune globulin.
Choice B Reason:
"I will receive this medication when I am in labor." This statement does not record understanding of the teaching. Rho(D) immune globulin is typically given around 28 weeks of pregnancy and possibly after events that could lead to mixing of maternal and fetal blood, not specifically during labor.
Choice C Reason:
"I will need a second dose of this medication when my baby is 6 weeks old." This statement does not record understanding of the teaching. The administration of Rho(D) immune globulin is generally based on events during pregnancy and delivery, and a second dose is not typically given postpartum unless the baby is Rh-positive.
Choice D Reason:
"I will need this medication if I have an amniocentesis." This statement records understanding of the teaching. Rho(D) immune globulin is given to Rh-negative women during pregnancy and certain other situations to prevent the development of Rh incompatibility with a Rh-positive baby. If the mother undergoes procedures such as amniocentesis or experiences events that could lead to mixing of maternal and fetal blood, Rho(D) immune globulin is administered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D.
A. Slowing the client's rate of breathing is not directly related to the observed uniform decelerations. The primary concern is the fetal heart rate pattern.
B. Decreasing the rate of infusion of the maintenance IV solution is not the appropriate intervention for addressing the observed fetal heart rate decelerations. The focus should be on the oxytocin infusion rate.
C. Increasing the rate of infusion of the IV oxytocin is not the appropriate action.
The patient is already experiencing frequent and strong contractions, and increasing the oxytocin rate can exacerbate the decelerations and compromise fetal well-being.
D. Discontinuing the infusion of the IV oxytocin is the correct action.
The observed uniform decelerations are likely related to oxytocin-induced hyperstimulation of the uterus. Stopping or decreasing the oxytocin infusion allows for the uterine activity to decrease, potentially improving fetal heart rate patterns.
Correct Answer is C
Explanation
The correct answer is C.
A. Acrocyanosis of the extremities: Acrocyanosis, or blueness of the extremities, is a common finding in newborns and is usually considered normal. It often resolves on its own and doesn't typically require intervention.
B. Murmur at the left sternal border: It's not uncommon for newborns to have innocent murmurs, and many resolve on their own as the infant grows. A murmur at the left sternal border alone may not necessarily indicate a problem, but it should be assessed by a healthcare provider.
C. Substernal chest retractions while sleeping: Chest retractions can be a sign of respiratory distress, and intervention is needed to assess and address the cause. Substernal retractions suggest increased work of breathing and may indicate a respiratory issue that requires attention.
D. Positive Babinski reflex: The Babinski reflex is a normal neurological response in infants. It involves the toes fanning out when the sole of the foot is stroked. A positive Babinski reflex is expected in a 12-hour-old newborn and does not require intervention.
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