A charge nurse is teaching a newly licensed nurse about Rho(D) immune globulin administration. Which of the following should the charge nurse include as an indication for the administration of Rho(D) immune globulin?
Hyperemesis gravidarum
Rh-positive blood test results
Prescription for an amniocentesis
Anemia
The Correct Answer is C
This is because a prescription for an amniocentesis is an indication for the administration of Rho(D) immune globulin (RhIG) to prevent RhD isoimmunization in mothers who are RhD negative¹². RhD isoimmunization is a condition where the mother's immune system produces antibodies against the RhD antigen on the baby's red blood cells, which can cause hemolytic disease of the newborn (HDN)¹². RhIG is a medication that contains antibodies against the RhD antigen, and it works by binding to and destroying any fetal red blood cells that may enter the maternal circulation, preventing the mother from making her own antibodies¹²³. RhIG is usually given to RhD negative mothers during pregnancy and after delivery if the baby is RhD positive¹².
Amniocentesis is a procedure where a needle is inserted into the uterus to obtain a sample of amniotic fluid, which contains fetal cells and other substances⁴. Amniocentesis can be done for various reasons, such as genetic testing, fetal lung maturity assessment, or infection diagnosis⁴. However, amniocentesis also carries a risk of causing bleeding or leakage of amniotic fluid, which can result in fetal-maternal hemorrhage (FMH), where fetal blood cells enter the maternal circulation⁴⁵. FMH can trigger RhD isoimmunization in RhD negative mothers, so they should receive RhIG within 72 hours of the procedure to prevent this complication⁵.
The other options are not correct because:
a) Hyperemesis gravidarum is not an indication for RhIG administration. Hyperemesis gravidarum is a condition where the mother experiences severe nausea and vomiting during pregnancy, which can cause dehydration, electrolyte imbalance, and weight loss. Hyperemesis gravidarum does not affect the blood type or compatibility of the mother and the baby, and does not increase the risk of RhD isoimmunization or HDN.
b) Rh-positive blood test results are not an indication for RhIG administration. Rh-positive blood test results mean that the mother has the RhD antigen on her red blood cells, and therefore she cannot develop antibodies against it¹². Rh-positive mothers do not need RhIG, as they are not at risk of RhD isoimmunization or HDN¹².
d) Anemia is not an indication for RhIG administration. Anemia is a condition where the mother has a low level of hemoglobin or red blood cells, which can cause fatigue, weakness, and shortness of breath. Anemia can have various causes, such as iron deficiency, bleeding, or infection. Anemia does not affect the blood type or compatibility of the mother and the baby, and does not increase the risk of RhD isoimmunization or HDN.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Among the given options, the client who has hyperemesis gravidarum and a sodium level of 110 mEq/L should be assessed first. Hyperemesis gravidarum is a condition characterized by severe and persistent vomiting during pregnancy, leading to dehydration and electrolyte imbalances. A sodium level of 110 mEq/L indicates hyponatremia, which is an abnormally low level of sodium in the blood.
Hyponatremia can lead to serious complications, including neurological symptoms such as confusion, seizures, and coma. Prompt assessment and intervention are necessary to correct the electrolyte imbalance and prevent further complications.
Option a) A client with preeclampsia and a creatinine level of 1.1 mg/dL should be monitored closely, as elevated creatinine levels can indicate impaired kidney function. However, in this scenario, the client with hyperemesis gravidarum and severe hyponatremia requires more immediate attention due to the potential for neurological complications.
Option c) A client with diabetes mellitus and an HbA1C of 5.8% may require further management and monitoring, but it does not present an immediate risk or urgency compared to the client with hyperemesis gravidarum and severe hyponatremia.
Option d) A client with placenta previa and a hematocrit of 35% may need close monitoring for potential bleeding, but it does not pose an immediate threat compared to the client with hyperemesis gravidarum and severe hyponatremia.
Therefore, the nurse should assess the client who has hyperemesis gravidarum and a sodium level of 110 mEq/L as the first priority due to the risk of complications associated with severe hyponatremia.
Correct Answer is D
Explanation
A pudendal nerve block is a local anesthetic administered to block the pudendal nerve, which supplies sensation to the perineum and external genitalia. It is commonly used during childbirth to provide pain relief during the second stage of labor.
An adverse effect of a pudendal nerve block is a decreased ability to bear down, or a decreased ability to push effectively during labor. This is because the block affects the nerves responsible for the contraction of the pelvic floor muscles, which are necessary for effective pushing during delivery.
Option a) Uterine hyperstimulation is not an adverse effect of a pudendal nerve block. Uterine hyperstimulation refers to excessive contractions of the uterus, often caused by medications such as oxytocin. Pudendal nerve block does not directly affect uterine contractions.
Option b) Maternal hypertension is not an adverse effect of a pudendal nerve block. Hypertension refers to
high blood pressure, and it is not typically associated with a pudendal nerve block.
Option c) Fetal bradycardia is not a common adverse effect of a pudendal nerve block. Fetal bradycardia refers to a slow heart rate in the fetus. While fetal heart rate monitoring is important during labor, bradycardia is not typically associated with a pudendal nerve block.
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