A nurse is teaching a pregnant client who is Rh-negative about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?
"If my partner is Rh-negative, I will not receive the shot."
"I will receive the shot after delivery if my baby is Rh-negative."
"I should not receive any immunizations for 3 months after the shot."
"This shot may be given after birth to protect future pregnancies."
The Correct Answer is D
A. "If my partner is Rh-negative, I will not receive the shot.": Incorrect. Rho(D) immune globulin is administered based on the Rh status of the baby, not the partner. The client will receive the shot if the baby is Rh-positive or if the Rh status is unknown.
B. "I will receive the shot after delivery if my baby is Rh-negative.": Incorrect. Rho(D) immune globulin is given after delivery if the baby is Rh-positive. If the baby is Rh-negative, the shot is not necessary.
C. "I should not receive any immunizations for 3 months after the shot.": Incorrect. There are no restrictions on receiving other immunizations after receiving Rho(D) immune globulin, and there is no need to wait for 3 months.
D. "This shot may be given after birth to protect future pregnancies.": Correct. Rho(D) immune globulin is given postpartum if the baby is Rh-positive to prevent the development of antibodies that could affect future pregnancies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Peanut butter sandwich: Incorrect. Peanut butter contains phenylalanine, an amino acid that people with phenylketonuria (PKU) must limit in their diet. Foods high in phenylalanine should be avoided to prevent complications.
B. Sliced apples: Correct. Sliced apples are low in phenylalanine and safe for individuals with PKU. Fruits are generally recommended for PKU patients as they provide essential nutrients without significant amounts of phenylalanine.
C. Glass of skim milk: Incorrect. Milk, including skim milk, contains phenylalanine, which should be limited or avoided by individuals with PKU. They need to consume specially formulated low-phenylalanine products.
D. Scrambled egg: Incorrect. Eggs are high in phenylalanine and should be avoided by individuals with PKU. They need to choose low-protein alternatives that do not contribute to their phenylalanine levels.
Correct Answer is A
Explanation
A. Respiratory rate 11/min: Correct. A respiratory rate of 11/min is below the normal range and could indicate magnesium sulfate toxicity, which can depress respiratory function. This finding requires prompt reporting to prevent further complications.
B. Deep tendon reflexes 2+: Incorrect. Deep tendon reflexes of 2+ are within the normal range and are not indicative of magnesium sulfate toxicity. Normal reflexes suggest that the magnesium level is likely within the therapeutic range.
C. Urine output 30 mL/hr: Incorrect. While urine output should be monitored in clients receiving magnesium sulfate, 30 mL/hr is on the lower end of normal but not necessarily an immediate cause for concern unless it is persistently low or accompanied by other symptoms.
D. Blood pressure 100/62 mm Hg: Incorrect. This blood pressure reading is within the acceptable range for a pregnant client on magnesium sulfate. Magnesium sulfate is used to prevent seizures and does not typically affect blood pressure in this manner.
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