A nurse is planning to administer Rh(D) immune globulin to a client who is postpartum.
Which of the following actions should the nurse take?
Verify that the newborn is Rh-negative.
Verify that the client’s Coombs test is positive.
Administer the medication within 72 hours after birth.
Administer the medication into the client’s abdomen.
The Correct Answer is C
Choice A rationale
Verifying that the newborn is Rh-negative is not necessary for administering Rh(D) immune globulin. The medication is given to Rh-negative mothers to prevent Rh sensitization, regardless of the newborn’s Rh status.
Choice B rationale
A positive Coombs test indicates that the mother has already been sensitized to Rh-positive blood cells, making Rh(D) immune globulin ineffective in preventing sensitization.
Choice C rationale
Administering Rh(D) immune globulin within 72 hours after birth is crucial to prevent Rh sensitization in future pregnancies. This timing ensures that the mother’s immune system does not produce antibodies against Rh-positive blood cells.
Choice D rationale
Rh(D) immune globulin is typically administered intramuscularly, not into the abdomen. The preferred sites are the deltoid muscle or the anterolateral aspect of the thigh.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Nursing the baby for 5 to 10 minutes on each breast may not be sufficient for the baby to receive the hindmilk, which is rich in fat and essential for growth.
Choice B rationale
Applying vitamin E oil to the nipples after each feeding is not recommended as it can cause irritation and is not necessary for nipple care.
Choice C rationale
Laying the baby on a pillow at the level of the breast helps ensure proper positioning and latch, which is crucial for effective breastfeeding and preventing nipple soreness.
Choice D rationale
Ensuring that just the nipple is in the baby’s mouth is incorrect. The baby should latch onto the areola, not just the nipple, to ensure effective milk transfer and prevent nipple pain.
Correct Answer is A
Explanation
The correct answer is Choice A
Choice A rationale: Using a breast pump helps maintain milk supply and prevent milk stasis, which reduces the risk of developing mastitis. Mastitis is an infection of the breast tissue that can cause pain, swelling, warmth, and redness.
Choice B rationale: Covering breasts immediately after feedings does not directly prevent mastitis. Proper hygiene and ensuring complete breast emptying are more effective measures for preventing mastitis. Covering may trap moisture and bacteria, potentially leading to infection.
Choice C rationale: Wearing an underwire bra between feedings can restrict milk flow and cause clogged ducts, increasing the risk of mastitis. Non-restrictive, well-fitting bras are recommended to ensure proper milk drainage and breast comfort.
Choice D rationale: Washing nipples with soap and water daily can strip natural oils, causing dryness and cracks. Cracked nipples are entry points for bacteria, increasing mastitis risk. Instead, cleaning with plain water is recommended to maintain nipple integrity.
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