A pregnant client receives Rho(D) immune globulin after an amniocentesis. The day following the procedure the client calls the nurse to report a temperature of 99.8° F (37.67°C). Which action should the nurse implement?

Instruct the client to maintain bed rest for 24 hours.

Encourage the client to increase her intake of oral fluids

Schedule a visit with the healthcare provider today

Verify the administered Rho(D) immune globulin's compatibility

Answer and Explanation

The Correct Answer is C

A. Instruct the client to maintain bed rest for 24 hours:
There is no clear indication for bed rest based solely on a slightly elevated temperature. Bed rest is not a standard recommendation for this situation.

B. Encourage the client to increase her intake of oral fluids:
Increasing fluid intake is a general recommendation for mild elevations in temperature. Adequate hydration can support the body's natural response to infection or inflammation.

C. Schedule a visit with the healthcare provider today:
This option is a prudent choice. A temperature elevation after a medical procedure may indicate an infection, and it's appropriate to schedule a visit with the healthcare provider for further evaluation.

D. Verify the administered Rho(D) immune globulin's compatibility:
While verifying the compatibility of the administered medication is important, it is not the primary concern when a client reports an elevated temperature. In this context, addressing the temperature and potential infection takes precedence.

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Correct Answer is A

Explanation

Inspect the client's face for edema:
Elevated blood pressure during pregnancy may be a sign of preeclampsia, a condition that can involve fluid retention. Edema, particularly in the face, is one of the signs that the nurse should assess for in determining if preeclampsia is a concern.

Ascertain the frequency of headaches:
Frequent headaches can be a symptom of various conditions, including preeclampsia. Gathering information about the frequency and characteristics of headaches can provide additional data for assessing the client's overall condition.

Evaluate for history of cluster headaches:
Cluster headaches, while severe, are not typically associated with elevated blood pressure during pregnancy. This information might not be directly relevant to the client's current symptoms.

Observe and time client's contractions:
Contractions are not typically associated with nausea, vomiting, or elevated blood pressure during pregnancy. This action may not address the primary concerns presented by the client.

A. Place the newborn in a position with the head lower than the feet. B. Turn the newborn to the side and bulb suction the mouth and nares. C. Wipe away the spit-up and assist the mother with the diaper change D. Sit the newborn upright and burp by rubbing or patting the upper back

Correct Answer is D

Explanation

A. Place the newborn in a position with the head lower than the feet:

This position might be used in cases of choking or difficulty breathing, but it's not typically the first response to spitting up.

B. Turn the newborn to the side and bulb suction the mouth and nares:

Suctioning might be necessary if there's difficulty breathing or if there's an excessive amount of mucus. However, for typical spit-up, this might be an unnecessary intervention.

C. Wipe away the spit-up and assist the mother with the diaper change:

Addressing the immediate concern by cleaning up and assisting with the diaper change is a reasonable first step, but it doesn't directly address the spit-up.

D. Sit the newborn upright and burp by rubbing or patting the upper back:

This is a common and appropriate action after feeding to help release any trapped air and prevent or alleviate spit-up.

Breastfeeding techniques and Burping Positions. | Download Scientific Diagram

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A pregnant client receives Rho(D) immune globulin after an amniocentesis. The day following the procedure the client calls the nurse to report a temperature of 99.8° F (37.67°C). Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is 32 weeks gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?

Correct Answer is A

Explanation

After breast-feeding 10 minutes at each breast, a new mother calls the nurse to the postpartum room to help change the newborn's diaper. As the mother begins the diaper change, the newborn spits up the breast milk. What action should the nurse implement first?

Correct Answer is D

Explanation

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