A nurse is teaching a client who is postpartum and has an order for an injection of Rh, (D) immunoglobulin. Which of the following should be included in the teaching?
It prevents the formation of Rh antibodies in mothers who are Rh negative.
It destroys Rh antibodies in mothers who are Rh negative.
It prevents the formation of Rh antibodies in newborns who are Rh positive.
It destroys Rh antibodies in newborns who are Rh positive.
The Correct Answer is A
A. It prevents the formation of Rh antibodies in mothers who are Rh negative: Rh(D) immunoglobulin works by preventing the maternal immune system from recognizing and forming antibodies against Rh-positive fetal red blood cells. This is essential to protect future pregnancies from hemolytic disease of the newborn.
B. It destroys Rh antibodies in mothers who are Rh negative: Rh(D) immunoglobulin does not destroy antibodies that have already formed. If sensitization has occurred, the immunoglobulin is ineffective. It is strictly a preventive measure, not a treatment for existing antibodies.
C. It prevents the formation of Rh antibodies in newborns who are Rh positive: Newborns do not form Rh antibodies in response to their own blood type. The immune response in question occurs in the Rh-negative mother, not in the Rh-positive infant. This statement reflects a misunderstanding of the immunologic mechanism.
D. It destroys Rh antibodies in newborns who are Rh positive: Rh(D) immunoglobulin does not act on the newborn’s immune system or antibodies. It functions solely in the maternal circulation to prevent maternal sensitization to fetal Rh-positive cells.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. It prevents the formation of Rh antibodies in mothers who are Rh negative: Rh(D) immunoglobulin works by preventing the maternal immune system from recognizing and forming antibodies against Rh-positive fetal red blood cells. This is essential to protect future pregnancies from hemolytic disease of the newborn.
B. It destroys Rh antibodies in mothers who are Rh negative: Rh(D) immunoglobulin does not destroy antibodies that have already formed. If sensitization has occurred, the immunoglobulin is ineffective. It is strictly a preventive measure, not a treatment for existing antibodies.
C. It prevents the formation of Rh antibodies in newborns who are Rh positive: Newborns do not form Rh antibodies in response to their own blood type. The immune response in question occurs in the Rh-negative mother, not in the Rh-positive infant. This statement reflects a misunderstanding of the immunologic mechanism.
D. It destroys Rh antibodies in newborns who are Rh positive: Rh(D) immunoglobulin does not act on the newborn’s immune system or antibodies. It functions solely in the maternal circulation to prevent maternal sensitization to fetal Rh-positive cells.
Correct Answer is A
Explanation
A. Respiratory rate of 8 breaths per minute: A respiratory rate below 12 breaths per minute is a sign of magnesium toxicity. Magnesium sulfate can depress the central nervous system, and a rate of 8 indicates potential respiratory compromise, requiring immediate intervention and possible discontinuation of the infusion.
B. Urine output of 60 mL in the past two hours: Although slightly low, this output is not yet at the critical level of concern. Urine output should be ≥30 mL/hr to ensure magnesium is excreted effectively. Continued monitoring is needed, but it does not require immediate action.
C. Deep tendon reflexes of +2: A +2 reflex is considered normal and indicates that the client is not currently experiencing neuromuscular depression. Loss or absence of reflexes would be more concerning for magnesium toxicity.
D. Complaints of mild nausea and flushing: These are common and expected side effects of magnesium sulfate therapy. While they should be documented and monitored, they do not suggest toxicity and do not require urgent intervention.
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.