A charge nurse is teaching a newly licensed nurse about Rh,(D) immune globulin administration. Which of the following should the charge nurse include as an indication for the administration of Rho(D) immune globulin?
Prescription for an amniocentesis
Anemia
Hyperemesis gravidarum
Rh-positive blood test results
The Correct Answer is D
: Rh-positive blood test results. Rho(D) immune globulin is indicated for Rh-negative women who are pregnant and for those who have had a miscarriage, ectopic pregnancy, or induced abortion. It is also indicated for Rh-negative women who give birth to Rh-positive infants. The administration of Rho(D) immune globulin prevents the Rh-negative mother from forming antibodies against Rh-positive fetal cells that may have entered her bloodstream.
Choice A, prescription for an amniocentesis, is not an indication for the administration of Rho(D) immune globulin. Choice B, anemia, and choice C, hyperemesis gravidarum, are also not indications for the administration of Rho(D) immune globulin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Pour warm water over the client's perineum. The nurse should first attempt non-invasive measures to treat bladder distention, such as pouring warm water over the client's perineum, to promote relaxation of the perineal muscles and increase urinary flow. If this measure is unsuccessful, the nurse may need to proceed with catheterization. However, catheterization can increase the client's risk for infection and trauma, so it should not be the first-line intervention. A sitz bath can also be helpful in treating bladder distention but is not as effective as warm water application directly to the perineum. Assisting the client to the bathroom is not indicated since the client is experiencing bladder distention, which can lead to difficulty emptying the bladder.
Correct Answer is A
Explanation
A. Apply a cap to the newborn's head: This is an appropriate intervention to conserve heat in a mildly hypothermic newborn. It is a standard practice to maintain thermal neutrality, especially in the first hours after birth.
B. Give the newborn a warm bath: Bathing is not appropriate for a newborn with a low temperature. Bathing could worsen heat loss and further lower the newborn's body temperature.
C. Reposition the newborn: While repositioning may improve comfort or support effective respiration, it does not directly address the low temperature.
D. Obtain an oxygen saturation level: The respiratory rate (50/min) and heart rate (130/min) are within the normal range for a newborn. Unless other signs of respiratory distress or cyanosis are present, this action is unnecessary.
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