A patient is a gravida 1. Rh-negative woman at a 28 weeks gestation. The father of her child is Rh- positive. The mother is asking the nurse about the effect on her unborn child of RhoGAM that has been ordered. What is the nurse's best reply?
"Your child will do well after birth once transfusions are administered.”
"RhoGAM kills antibodies you make, so your kid will be protected."
"Your baby may be Rh positive and cause you to make antibodies. These won't affect this baby, but could affect future children If RhoGAM isn't given."
“If the baby is RH negative at birth, he or she will need Rho GAM also”
The Correct Answer is C
A. "Your child will do well after birth once transfusions are administered": This statement focuses on postnatal intervention rather than preventing maternal sensitization during pregnancy, which is the primary purpose of RhoGAM.
B. "RhoGAM kills antibodies you make, so your kid will be protected": RhoGAM does not destroy existing antibodies; it prevents the formation of maternal antibodies against Rh-positive fetal cells. This explanation could mislead the patient.
C. "Your baby may be Rh positive and cause you to make antibodies. These won't affect this baby, but could affect future children if RhoGAM isn't given": RhoGAM prevents maternal sensitization by neutralizing fetal Rh-positive red blood cells before the immune system responds. This explanation clearly communicates the purpose of the medication and the relevance for future pregnancies.
D. "If the baby is Rh negative at birth, he or she will need RhoGAM also": RhoGAM is administered to the mother, not the baby, and is only necessary if the mother is Rh-negative and the fetus is Rh-positive.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Administer analgesics: Pain control is essential after a tonsillectomy to promote oral intake and comfort. Analgesics reduce throat discomfort and help the child maintain hydration and nutrition, but they do not directly prevent life-threatening complications such as postoperative hemorrhage.
B. Encourage the child to drink liquids: Hydration supports mucosal healing and prevents dehydration, which is a common postoperative concern. However, while encouraging fluid intake is important, it does not directly address the risk of sudden, severe bleeding that can occur after tonsillectomy.
C. Inspect the throat for bleeding: Post-tonsillectomy hemorrhage is the most serious complication, especially within the first 24 hours and around 5–10 days post-surgery when the scabs begin to slough. Careful observation for signs of active bleeding, such as frequent swallowing, vomiting blood, or fresh blood in the mouth, is critical to detect hemorrhage early.
D. Apply an ice collar: Ice collars can reduce local swelling and provide comfort by constricting blood vessels, helping with pain control. Although beneficial, this intervention does not address the immediate danger posed by postoperative bleeding and is secondary to monitoring for hemorrhage.
Correct Answer is B
Explanation
A. Fitting contraceptive device for the client: While placing devices like IUDs or implants is part of family planning, it is a procedure that requires prior assessment and informed consent. Immediate placement without education or discussion may not ensure understanding or adherence.
B. Providing detailed education to the client: Education is central to family planning counselling. Explaining options, effectiveness, potential side effects, and proper use empowers the client to make informed choices and supports safe, autonomous decision-making.
C. Offering emergency contraception to the client: Emergency contraception is time-sensitive and situational. It may be part of family planning services but is not the primary or most appropriate action during general counselling sessions.
D. Discussing preferences with the client's partner: Including the partner may be appropriate if the client desires, but counselling should prioritize the client’s autonomy and individual choice, ensuring their preferences are understood first.
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