A nurse on a postpartum unit is assisting with the care of four clients. The nurse should identify that which of the following clients should receive Rh (D. immune globulin?
An Rh-negative client who has an Rh-negative newborn
An Rh-negative client who has an Rh-positive newborn
An Rh-positive client who has an Rh-positive newborn
An Rh-positive client who has an Rh-negative newborn
The Correct Answer is B
A. If both the mother and the newborn are Rh-negative, there is no need for Rh (D. immune globulin.
B. An Rh-negative mother carrying an Rh-positive baby is at risk for Rh incompatibility. She should receive Rh (D. immune globulin to prevent sensitization.
C. If both the mother and the newborn are Rh-positive, there is no need for Rh (D. immune globulin.
D. If the mother is Rh-positive and the newborn is Rh-negative, there is no need for Rh (D. immune globulin.
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Related Questions
Correct Answer is D
Explanation
A: Administering the medication into the deltoid muscle is not recommended for newborns due to their underdeveloped muscle mass and the potential for injury. The vastus lateralis muscle in the thigh is the preferred site for intramuscular injections in infants.
B: Checking the mother's Rh factor is not directly related to the administration of phytonadione, which is given to prevent vitamin K deficiency bleeding in the newborn, a condition unrelated to the mother's Rh factor.
C: Administering the medication 12 hours after birth is not the standard practice. Phytonadione is typically given within the first hour after birth to ensure prompt prevention of hemorrhagic disease of the newborn.
D: Administering the medication with a 25 gauge needle is appropriate as it is small enough to cause minimal discomfort and large enough to ensure proper delivery of the medication into the infant's muscle tissue.
Correct Answer is B
Explanation
A. Incorrect. While using a disposable razor is a precaution for individuals taking anticoagulants to reduce the risk of bleeding, it is not specific to warfarin.
B. Correct. Taking oral contraceptives along with warfarin can increase the risk of bleeding.
Therefore, the client should be advised not to take oral contraceptives while on warfarin.
C. Incorrect. Aspirin is not typically recommended for pain relief in individuals taking warfarin due to the increased risk of bleeding.
D. Incorrect. The duration of warfarin therapy is individualized based on the specific condition being treated. It is not a fixed 2-week period.
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