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:
Elevating the client's legs can improve venous return and cardiac output, but it does not directly address the underlying cause
of late decelerations, which is uteroplacental insufficiency.
While elevating the legs may have some benefit, it's not the most effective initial action to address late decelerations.
It's important to prioritize interventions that directly improve uteroplacental blood flow.
Choice C rationale:
Increasing the infusion rate of IV fluids can expand maternal blood volume, but it may not significantly improve uteroplacental
perfusion if there's underlying placental insufficiency.
It's not the most effective initial action to address late decelerations.
It may be considered as a secondary measure if repositioning doesn't resolve the decelerations.
Choice D rationale:
Administering oxygen via face mask can improve fetal oxygenation, but it does not directly address the underlying cause of
late decelerations, which is uteroplacental insufficiency.
It's not the most effective initial action to address late decelerations.
It may be considered as an adjunct measure to improve fetal oxygenation, but it's not a primary intervention for late
decelerations.
Choice B rationale:
Positioning the client on her side is the most effective initial action to address late decelerations because it:
Relieves pressure on the vena cava, which improves venous return and cardiac output.
Increases placental perfusion by increasing blood flow to the uterus.
This can help to correct fetal hypoxia and improve fetal heart rate patterns.
It's a simple, non-invasive intervention that can be quickly implemented and has a high success rate in resolving late
decelerations.
Correct Answer is A
Explanation
Choice A rationale:
Fever: A hallmark sign of inflammation, fever is a common and often early manifestation of endometritis. The body's
thermostat, located in the hypothalamus, is reset to a higher temperature in response to infection or inflammation. This
triggers a cascade of physiological events, including chills, shivering, and increased heat production, as the body attempts to
fight off pathogens. In endometritis, the fever is typically 100.4°F (38°C) or higher.
Chills: Often accompanying fever, chills are a sensation of coldness despite a normal or elevated body temperature. They result
from involuntary muscle contractions, which generate heat in an attempt to raise the body's temperature. Chills can be mild or
severe, and they often precede a rise in temperature.
Choice B rationale:
Increased heart rate: Tachycardia, or an increased heart rate, can occur in endometritis, but it is not a specific finding. It can be
present in various other conditions, including anxiety, pain, dehydration, anemia, and other infections. While it may be a sign
of endometritis, it's not considered a primary manifestation.
Choice C rationale:
Lower abdominal pain: Lower abdominal pain is a common symptom in postpartum women, but it is not always indicative of
endometritis. It can result from uterine contractions, incisional pain (if a cesarean section was performed), bladder distention,
constipation, or other postpartum complications. While it may be present in endometritis, it's not a specific finding.
Choice D rationale:
Unusual vaginal discharge: Lochia, the normal postpartum vaginal discharge, can vary in color and amount. However, unusual
vaginal discharge, such as foul-smelling or purulent discharge, can be a sign of endometritis. It's important to note that not all
women with endometritis will have abnormal discharge.
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