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.
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Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
The nurse should plan toB. check the client’s blood glucose levelandA. obtain a urine sample to test for ketones.
Explanation:
- Check the client’s blood glucose level: Given the client’s history of type 1 diabetes mellitus and her current symptoms (diaphoresis, clammy skin, headache, nausea, and weakness), it is crucial to check her blood glucose level to rule out hypoglycemia or hyperglycemia, despite the recent blood glucose reading of 120 mg/dL.
- Obtain a urine sample to test for ketones: Testing for ketones is important in diabetic patients, especially when they present with symptoms that could indicate diabetic ketoacidosis (DKA), such as nausea, weakness, and a history of type 1 diabetes.
Correct Answer is A
Explanation
Choice A rationale
Eating dry, bland foods in the morning can help alleviate nausea by providing a gentle start to the digestive system. Bland foods like crackers or toast are less likely to irritate the stomach lining and can help absorb stomach acids, reducing the feeling of nausea.
Choice B rationale
Taking an over-the-counter antacid is not recommended for nausea during pregnancy unless prescribed by a healthcare provider. Antacids are typically used to neutralize stomach acid and relieve heartburn, not nausea.
Choice C rationale
Restricting fluids to 1,000 mL/day is not advisable as it can lead to dehydration. Adequate hydration is essential during pregnancy to support the increased blood volume and amniotic fluid.
Choice D rationale
Increasing the intake of fresh fruits is beneficial for overall health but may not specifically address nausea. Some fruits can be acidic and might worsen nausea in some individuals.
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