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

Choice A rationale:

Blood pressure of 136/88 mm Hg should be monitored, but it is not a finding that the nurse needs to urgently report to the provider following the administration of butorphanol. The blood pressure reading is slightly elevated but might be attributed to pain or anxiety during labor.

Choice B rationale:

Moderate fetal heart rate variability is a reassuring sign of fetal well-being and is an expected finding during labor. It does not require immediate reporting to the provider.

Choice C rationale:

C. Respiratory rate 100/min: A respiratory rate of 100/min is indicative of tachypnea, which could suggest maternal distress, hypoxemia, or an adverse reaction to the medication. While opioids typically depress respiration, this finding is abnormal and warrants immediate evaluation to rule out complications such as maternal anxiety, pain, or hypoxia.

Choice D rationale:

Urinary output of 120 mL in 2 hours is an acceptable finding during labor and does not require immediate reporting to the provider. Adequate urinary output varies, but generally, 30 mL/hour is considered acceptable during labor.

A. Feed the newborn 5 to 10 min per breast. B. Allow the baby to feed at least every 3 hr. C. Offer the newborn 30 mL (1 oz) of water between feedings. D. Expect two to four wet diapers every 24 hr.

Correct Answer is B

Explanation

The correct answer is choice B, "Allow the baby to feed at least every 3 hr." The nurse should instruct the client who is breastfeeding her newborn to allow the baby to feed at least every 3 hr, which can help to establish an adequate milk supply. The client should also be instructed to feed the newborn on demand, offer both breasts at each feeding, and continue to breastfeed for as long as the baby is interested. The nurse should advise the client to expect at least six to eight wet diapers every 24 hr and monitor the newborn for signs of dehydration, such as a decrease in urine output, dry mucous membranes, or lethargy.

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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

A nurse is caring for a client who is in active labor. The nurse administers butorphanol IV bolus for pain. Which of the following findings should the nurse report to the provider following this medication?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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