A nurse is caring for a client who is postpartum.
Which of the following findings is an indication for the nurse to administer Rho(D) immune globulin?
The client is Rh positive and the newborn is Rh positive
The client is Rh positive and the newborn is Rh negative
The client is Rh negative and the newborn is Rh negative
The client is Rh negative and the newborn is Rh positive
The Correct Answer is D
Choice A rationale:
Rh positive individuals already have the Rh factor on their red blood cells, so they do not need Rho(D) immune globulin to
prevent sensitization.
The newborn being Rh positive does not pose a risk to an Rh positive mother, as their blood types are compatible.
Choice B rationale:
Rh positive individuals cannot develop antibodies against the Rh factor, as it is already present on their own red blood cells.
The newborn's Rh negative status does not create a risk of sensitization for the mother, as there is no Rh factor to trigger an
immune response.
Choice C rationale:
If both the mother and the newborn are Rh negative, there is no risk of Rh incompatibility.
This is because neither individual has the Rh factor on their red blood cells, so there is no potential for sensitization.
Choice D rationale:
When an Rh negative mother carries an Rh positive fetus, there is a risk of Rh sensitization during pregnancy and delivery.
This occurs when fetal blood cells cross the placenta and enter the mother's bloodstream, exposing her immune system to the
Rh factor.
If the mother's immune system recognizes the Rh factor as foreign, it can produce antibodies against it.
These antibodies can cross the placenta in subsequent pregnancies and attack the red blood cells of Rh positive fetuses,
leading to hemolytic disease of the newborn (HDN).
Rho(D) immune globulin is a medication that can prevent Rh sensitization by binding to Rh positive fetal blood cells that have
entered the mother's bloodstream.
This prevents the mother's immune system from recognizing the Rh factor and producing antibodies.
Rho(D) immune globulin is typically given to Rh negative mothers within 72 hours of delivery of an Rh positive newborn, as well as after other events that could lead to Rh sensitization, such as miscarriage, abortion, or ectopic pregnancy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
There is no evidence to suggest that epidural anesthesia delays the rupture of fetal membranes. The timing of rupture of fetal
membranes is influenced by various factors, including the strength of uterine contractions, the position of the baby, and the
elasticity of the amniotic sac. Epidural anesthesia does not directly affect these factors.
Choice B rationale:
Epidural anesthesia can prolong labor by interfering with the natural process of labor. It can weaken uterine contractions,
slow down cervical dilation, and potentially lead to a prolonged second stage of labor. This is because the anesthesia blocks the
nerve signals that control the muscles of the uterus. When these signals are blocked, the contractions may become less
frequent and less intense. This can delay the progress of labor and increase the risk of interventions such as forceps delivery
or cesarean section.
Choice C rationale:
While epidural anesthesia can have some effects on the baby, it is not a primary cause of fetal depression. Fetal depression is
typically caused by other factors, such as decreased oxygen supply to the baby, maternal infection, or placental problems.
Epidural anesthesia can sometimes lead to a temporary decrease in the baby's heart rate, but this is usually well-managed by
the healthcare team and does not typically lead to significant fetal depression.
Choice D rationale:
Epidural anesthesia does not typically cause maternal hypertension. In fact, it can sometimes have the opposite effect and
cause a slight decrease in blood pressure. This is because the anesthesia can relax the blood vessels, which can lead to a drop
in blood pressure. However, this is usually not a significant concern and is easily managed by the healthcare team.
Correct Answer is C
Explanation
Choice A rationale:
Stopping breastfeeding until the antibiotics are done is not a recommended practice. Most antibiotics are safe to use while
breastfeeding. Moreover, stopping breastfeeding can lead to engorgement.
Choice B rationale:
Applying cold compresses 20 minutes before each feeding is not a recommended practice. Cold compresses are usually
recommended after breastfeeding to help reduce swelling. Warm compresses or taking a warm shower before breastfeeding
can help increase milk flow and promote the letdown reflex.
Choice C rationale:
Feeding the baby every 2 hours is a good practice to prevent breast engorgement. Frequent feeding helps to empty the breasts,
which can prevent them from becoming overly full and engorged.
Choice D rationale:
Not wearing a bra during the daytime is not a recommended practice. Wearing a well-fitted bra can provide support and help
reduce discomfort associated with breast engorgement.
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