A nurse is teaching a pregnant client who is Rh-negative about Rh(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?
"If my partner is Rh-negative, I will not receive the shot.”
"I will receive the shot after delivery if my baby is Rh-negative.”
"I should not receive any immunizations for 3 months after the shot.”
"This shot may be given after birth to protect future pregnancies.”
The Correct Answer is D
Choice A rationale:
This statement is incorrect. The client should receive Rh(D) immune globulin (RhoGAM) if they are Rh-negative and their partner's Rh status is unknown or Rh-positive. This prevents the development of Rh antibodies in the mother's blood, which could be harmful in future pregnancies if the baby is Rh-positive.
Choice B rationale:
This statement is incorrect. Rh(D) immune globulin is administered to an Rh-negative mother within 72 hours after delivery if the baby is Rh-positive. This is done to prevent the mother from developing Rh antibodies that could affect subsequent pregnancies.
Choice C rationale:
This statement is incorrect. There is no restriction on receiving other immunizations after receiving Rh(D) immune globulin. The shot only protects against Rh incompatibility and does not interfere with other immunizations.
Choice D rationale:
This statement is correct. Rh(D) immune globulin can be given after birth to an Rh-negative mother with an Rh-positive baby. This helps protect the mother's future pregnancies from the potential harmful effects of Rh incompatibility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
The clinical finding of 0 station does not provide information about the fetal head's position in the left occiput posterior position. Station refers to the level of the presenting part in relation to the ischial spines, not the position.
Choice B rationale:
The clinical finding of 0 station does not indicate that the largest fetal diameter has passed through the pelvic outlet. The station only tells us the level of the presenting part and does not provide information about the diameter passing through the pelvic outlet.
Choice C rationale:
The clinical finding of 0 station does not directly involve the palpability of the posterior fontanel. Station is determined based on the level of the presenting part in the birth canal.
Choice D rationale:
This is the correct interpretation of the clinical finding. 0 station means that the presenting part (usually the baby's head) is at the level of the ischial spines, which serves as a reference point during labor. As labor progresses and the baby moves further down the birth canal, the station becomes more negative (e.g., -1, -2) until delivery occurs.
Correct Answer is D
Explanation
Choice A rationale:
Periodic tingling of fingers is a common symptom during pregnancy and is often related to hormonal changes and increased fluid retention. While it can be uncomfortable, it is not necessarily an indication of a potential prenatal complication.
Choice B rationale:
Absence of clonus is not an abnormal finding during pregnancy. Clonus is a series of involuntary muscle contractions and relaxations and is generally not expected during a routine assessment.
Choice C rationale:
Leg cramps are a common complaint during pregnancy and are usually caused by changes in calcium and magnesium levels. While they can be uncomfortable, they are not typically considered an indication of a potential prenatal complication.
Choice D rationale:
Blurred vision can be an indication of preeclampsia, a serious condition that can occur during pregnancy. Preeclampsia is characterized by high blood pressure and damage to organs, often affecting the eyes, kidneys, and liver. It is crucial for the nurse to recognize this symptom and promptly inform the healthcare provider for further evaluation and management.
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