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

Answer and Explanation

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.

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Correct Answer is C

Explanation

The nurse should report a respiratory rate of 10/min to the provider following the administration of butorphanol IV bolus. Butorphanol is an opioid agonist-antagonist analgesic that can cause respiratory depression as a side effect. Therefore, it is important to monitor the client's respiratory rate and depth closely after administration of the medication. A respiratory rate of 10/min is significantly lower than the normal range of 1220/min, and may indicate respiratory depression. The nurse should also monitor the client's blood pressure, urinary output, and fetal heart rate for any changes, but these findings are not necessarily indicative of a complication following the administration of butorphanol.

A. A client who has preeclampsia and a creatinine level of 1.1 mg/dL B. A client who has placenta previa and a hematocrit of 36% C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L D. A client who has diabetes mellitus and an HbA1c of 5.8%

Correct Answer is C

Explanation

The correct answer is choice C, the client who has hyperemesis gravidarum and a sodium level of 110 mEq/L should be assessed first. This client's low sodium level indicates hyponatremia, which can lead to seizures and brain damage if not corrected promptly. The nurse should assess the client's neurologic status, including level of consciousness, reflexes, and motor function, and notify the provider immediately. The other clients also require close monitoring and intervention, but their conditions are not as urgent as the client with hyponatremia. Clients with preeclampsia require monitoring of blood pressure and kidney function, clients with placenta previa require monitoring of bleeding and hematocrit levels, and clients with diabetes mellitus require monitoring of blood glucose levels and HbA1c.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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