A pregnant client receives Rho(D) immune globulin after an amniocentesis. The day following the procedure the client calls the nurse to report a temperature of 99.8° F (37.67°C). Which action should the nurse implement?
Instruct the client to maintain bed rest for 24 hours.
Encourage the client to increase her intake of oral fluids
Schedule a visit with the healthcare provider today
Verify the administered Rho(D) immune globulin's compatibility
The Correct Answer is C
A. Instruct the client to maintain bed rest for 24 hours:
There is no clear indication for bed rest based solely on a slightly elevated temperature. Bed rest is not a standard recommendation for this situation.
B. Encourage the client to increase her intake of oral fluids:
Increasing fluid intake is a general recommendation for mild elevations in temperature. Adequate hydration can support the body's natural response to infection or inflammation.
C. Schedule a visit with the healthcare provider today:
This option is a prudent choice. A temperature elevation after a medical procedure may indicate an infection, and it's appropriate to schedule a visit with the healthcare provider for further evaluation.
D. Verify the administered Rho(D) immune globulin's compatibility:
While verifying the compatibility of the administered medication is important, it is not the primary concern when a client reports an elevated temperature. In this context, addressing the temperature and potential infection takes precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administer oxygen via facemask: Oxygen administration is generally a step in managing fetal distress. However, when dealing with variable decelerations, the initial action involves repositioning the mother to alleviate potential cord compression, as variable decelerations are often due to compression of the umbilical cord.
B. Turn off the oxytocin infusion: If variable decelerations persist despite repositioning, it might be necessary to discontinue the oxytocin (Pitocin) infusion temporarily. Oxytocin can cause or exacerbate uterine hyperstimulation, which can contribute to fetal distress.
C. Assess cervical dilatation: Assessing cervical dilatation might be a part of the overall assessment but might not directly address the immediate issue of variable decelerations. However, it's essential to monitor the progress of labor as part of the broader assessment.
D. Change the client's position: This is the recommended first action for variable decelerations. Repositioning the mother, such as moving her to a lateral or knee-chest position, can relieve potential cord compression and improve fetal oxygenation.
Correct Answer is ["450"]
Explanation
- To calculate the infusion rate, use the formula:
(mL of solution / grams of drug) x (grams ordered / minutes to infuse) x 60
- In this case, the formula becomes: (500 mL / 20 g) x (6 g / 20 min) x 60
- Simplify and solve: (25 mL / g) x (0.3 g / min) x 60
- The answer is 450 mL/hour
- The nurse should set the infusion pump at 450 mL/hour
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