A pregnant client at 28 weeks of gestation, who is receiving Rho(D) immune globulin for her Rh-negative status, asks the nurse if she will need another dose later.
What is the most appropriate response from the nurse?

You will not need another dose since this is a one-time treatment for your entire pregnancy.

You will need to come back for a dose of Rho(D) immune globulin only if you experience bleeding or trauma.

You will need to receive another dose at delivery if your baby is Rh-positive.

You will need Rho(D) immune globulin again in 72 hours to protect any future pregnancies.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Rho(D) immune globulin provides passive immunity against the Rh D antigen. The effects of a single dose administered at 28 weeks typically last for about 12 weeks, which generally covers the remainder of the pregnancy. However, it does not provide lifelong protection.

Choice B rationale

While Rh-negative mothers receive Rho(D) immune globulin after events like bleeding or trauma that could lead to fetal-maternal hemorrhage, the standard protocol also includes a prophylactic dose at around 28 weeks gestation regardless of such events.

Choice C rationale

If the baby is Rh-positive, fetal red blood cells may enter the mother's circulation during delivery. To prevent the mother from developing Rh antibodies that could affect future Rh-positive pregnancies, another dose of Rho(D) immune globulin is necessary within 72 hours postpartum.

Choice D rationale

Rho(D) immune globulin given at 28 weeks primarily protects the current pregnancy. While it helps prevent sensitization that could affect future pregnancies, the 72-hour postpartum dose is specifically timed to address potential exposure to fetal Rh-positive blood during delivery of an Rh-positive infant.

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Correct Answer is B

Explanation

Choice A rationale

Symmetrical breast swelling with a sudden increase in milk production is characteristic of normal postpartum breast engorgement as lactation is established, not mastitis. Mastitis is usually localized to one breast.

Choice B rationale

Swelling and redness in one breast, accompanied by flu-like symptoms such as fever, chills, and body aches, are classic signs and symptoms of mastitis, an infection or inflammation of the breast tissue.

Choice C rationale

Bilateral breast tenderness and engorgement without fever are typical findings of normal postpartum breast engorgement, which occurs due to increased blood flow and milk production. Fever is a key indicator of infection, such as mastitis.

Choice D rationale

A white patch on a nipple is more indicative of thrush (candidiasis), a fungal infection that can occur during breastfeeding, affecting the nipple and the baby's mouth. While uncomfortable, it is distinct from mastitis.

A. Decreased sensation in the lower extremities. B. Respiratory depression. C. Blood pressure 108/62. D. Sustained fetal heart rate of 150 bpm. E. Slurred speech.

Correct Answer is ["B","E"]

Explanation

Choice A rationale

Decreased sensation in the lower extremities is an expected effect of epidural anesthesia. Epidurals work by blocking nerve signals in the lower spinal cord, leading to a reduction in feeling and motor function in the legs.

Choice B rationale

Respiratory depression is a serious complication of epidural anesthesia, although rare. The anesthetic can potentially migrate higher in the spinal cord and affect the nerves that control breathing. This requires immediate intervention by the anesthesiologist. Normal respiratory rate for an adult is 12-20 breaths per minute.

Choice C rationale

A blood pressure of 108/62 mm Hg is within the normal range for an adult and is not a cause for immediate concern in a client with an epidural. While hypotension can occur with epidurals, this value is stable. Normal systolic blood pressure is typically 90-120 mm Hg, and normal diastolic blood pressure is 60-80 mm Hg.

Choice D rationale

A sustained fetal heart rate of 150 bpm is within the normal range for a fetus during labor, which is typically 110-160 bpm. This finding does not indicate immediate distress requiring anesthesiologist intervention.

Choice E rationale

Slurred speech is not an expected effect of a properly placed epidural. It could indicate that the local anesthetic has migrated systemically, potentially affecting the central nervous system. This warrants immediate assessment by the anesthesiologist.

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A pregnant client at 28 weeks of gestation, who is receiving Rho(D) immune globulin for her Rh-negative status, asks the nurse if she will need another dose later.What is the most appropriate response from the nurse?

Nursing Test Bank

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A nurse is caring for a client who is 3 days postpartum and is attempting to breastfeed.Which of the following findings indicate mastitis?

Correct Answer is B

Explanation

A nurse is monitoring a client in active labor who has an epidural in place.Which of the following findings should be reported to the anesthesiologist immediately?

Correct Answer is ["B","E"]

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A pregnant client at 28 weeks of gestation, who is receiving Rho(D) immune globulin for her Rh-negative status, asks the nurse if she will need another dose later.
What is the most appropriate response from the nurse?