A nurse is caring for a client on postpartum day 2 who is preparing to go home with their newborn.
The nurse notes that the client's blood type is O- and the newborn's blood type is A+. Which of the following actions by the nurse is appropriate?
Ensure the client receives a Rho (D) Immune Globulin injection before they are discharged from the hospital.
Educate the client that because their newborn's blood type was A+, they do not require Rho (D) Immune Globulin.
Advise the client to keep their appointment with their physician at the end of the week to receive a Rho (D) Immune Globulin injection.
Inform the client's physician that because the client is being discharged home on the second day, the Rho (D) Immune Globulin injection could not be given.
The Correct Answer is A
Choice A rationale
The mother is O- and the newborn is A+, which creates a risk for Rh incompatibility. The mother's body has been exposed to the Rh-positive antigens from the newborn, potentially leading to the development of anti-Rh antibodies. To prevent the mother's immune system from developing these antibodies, which could affect a future Rh-positive pregnancy, a Rho (D) Immune Globulin injection must be administered. This injection needs to be given within 72 hours of delivery.
Choice B rationale
It is incorrect to educate the client that they do not require Rho (D) Immune Globulin. The Rh incompatibility between an Rh-negative mother and an Rh-positive newborn is the exact situation where Rho (D) Immune Globulin is indicated. The purpose of the injection is to prevent the maternal immune system from recognizing the Rh-positive fetal cells, thereby preventing the production of antibodies that could harm a subsequent pregnancy.
Choice C rationale
Advising the client to wait until their physician's appointment at the end of the week is inappropriate. Rho (D) Immune Globulin must be administered within 72 hours of delivery to be effective in preventing the sensitization of the mother's immune system. Delaying the injection beyond this window significantly reduces its effectiveness. Therefore, the injection must be given before the client is discharged from the hospital.
Choice D rationale
Informing the physician that the injection cannot be given due to the client being discharged is an inappropriate action. It is the nurse's responsibility to ensure that the client receives all necessary postpartum care before discharge. The Rho (D) Immune Globulin injection is a critical part of postpartum care for an Rh-negative mother with an Rh-positive newborn and must be administered within the hospital stay to ensure timely intervention
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Placing one hand on the fundus while the other is on the perineum is an incorrect technique. This method fails to provide counterpressure to the lower uterine segment, which is essential to prevent uterine inversion during fundal massage. The uterus must be stabilized to ensure safe and effective palpation and massage.
Choice B rationale
Palpating the fundus with only fingertip pressure is an incorrect technique. This light pressure is insufficient to accurately assess uterine tone and position. Effective palpation requires firm but gentle pressure to compress the uterine wall and determine its height, tone, and midline placement.
Choice C rationale
Placing one hand at the base of the uterus just above the symphysis pubis and one on the fundus is the recommended technique. This provides essential counterpressure to support the lower uterine segment and prevent uterine prolapse or inversion during palpation and massage, ensuring patient safety.
Choice D rationale
Resting both hands on the fundus is an incorrect technique. This method fails to provide adequate counterpressure to the lower uterine segment. Without this stabilization, there is an increased risk of uterine inversion when massaging or assessing the fundus, a potentially life-threatening complication.
Correct Answer is C
Explanation
Choice A rationale
Adjusting the intravenous fluid infusion rate is not the immediate priority after an amniotomy. This action is not directly related to the most critical and immediate potential complication of this procedure, which is a change in the fetal heart rate. The primary concern is the potential for umbilical cord prolapse, which can lead to fetal hypoxia.
Choice B rationale
Providing a clean gown and linens is important for client comfort and hygiene, but it is not the immediate priority. The nurse must first ensure the safety of the fetus by assessing for complications that can arise from the procedure, such as umbilical cord compression or prolapse, which can lead to fetal distress and requires immediate intervention.
Choice C rationale
The immediate priority after an amniotomy is to assess the fetal heart rate. The sudden release of amniotic fluid can cause the umbilical cord to prolapse and become compressed, leading to a rapid decrease in blood flow and oxygen to the fetus. This compression results in fetal bradycardia, a critical finding requiring immediate intervention to prevent fetal hypoxia and death.
Choice D rationale
Assisting the client to wash the perineum is a hygiene measure that can be performed after the immediate safety of the fetus has been established. It is not the priority action. The nurse must first rule out any life-threatening complications to the fetus, such as cord prolapse, which is a significant risk following the rupture of membranes.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.