Rh, immune globulin will be ordered after birth if which situation occurs?
Mother Rh-, baby Rh+
Mother Rh-, baby Rh-
Mother Rh+, baby Rh+
Mother Rh+, baby Rh-
The Correct Answer is A
A. Mother Rh-, baby Rh+:
Rh immune globulin (RhoGAM) is given to Rh-negative mothers after childbirth if the baby is Rh-positive. This is to prevent the mother from developing antibodies against Rh-positive blood cells, which could affect future pregnancies. If the mother’s immune system recognizes Rh-positive cells as foreign, it may start producing antibodies that can cross the placenta and harm future Rh-positive fetuses, potentially leading to hemolytic disease of the newborn. Administering RhoGAM prevents this sensitization from occurring.
B. Mother Rh-, baby Rh-:
If the mother is Rh-negative and the baby is also Rh-negative, there is no risk of Rh incompatibility. Since there is no Rh-positive blood in the mix, the mother will not develop antibodies against Rh-positive cells. Therefore, Rh immune globulin is not needed in this situation.
C. Mother Rh+, baby Rh+:
If the mother is Rh-positive, there is no risk of Rh incompatibility regardless of the baby’s Rh status. Rh-positive mothers do not produce antibodies against Rh-positive blood cells, so RhoGAM is unnecessary in this scenario.
D. Mother Rh+, baby Rh-:
Again, since the mother is Rh-positive, there is no risk of sensitization, even if the baby is Rh-negative. In this situation, the mother's immune system will not generate antibodies against Rh-negative blood cells, and RhoGAM is not needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Put baby to breast for non-nutritive sucking to calm baby:
Non-nutritive sucking (sucking without feeding) is a natural way for babies to self-soothe. It can help calm a fussy infant and also promote bonding between mother and baby. This action also stimulates milk production in the mother. It's a safe and effective way to comfort the baby without introducing unnecessary interventions. Non-nutritive sucking can help regulate the baby's sucking reflexes and provide comfort until the next feeding.
B) Give the baby pacifier:
While pacifiers can help some babies self-soothe, they can interfere with breastfeeding, especially in the early days. Introducing a pacifier too soon may confuse the baby’s natural sucking pattern and affect the latch, which can impact breastfeeding success. It’s typically recommended to wait until breastfeeding is well-established, around 3-4 weeks, before introducing a pacifier.
C) Put the baby in the nursery so mom can get some rest:
While maternal rest is important, removing the baby from the mother's care in the early postpartum period may interfere with the breastfeeding process. Breastfeeding on demand is crucial for establishing a good milk supply, and keeping the baby close for frequent feedings (and comfort) will help with this. Encouraging rest is important, but it shouldn't come at the expense of bonding and feeding.
D) Supplement with formula:
There is no indication that the baby is not getting enough nutrition at this point. Fussy behavior between feedings is common in newborns and can be due to various factors such as the baby's need for comfort, a growth spurt, or a short interval between feedings. Supplementing with formula is not necessary unless there is a clear indication of inadequate milk supply or other medical concerns, which isn’t evident in this situation.
Correct Answer is A
Explanation
A) Assess the woman's fundus and massage it if boggy:
A saturated pad within 15 minutes after delivery suggests a hemorrhage, and the first priority in this situation is to assess the fundus. If the fundus is boggy (soft and not contracted), it is a sign of uterine atony, which is the most common cause of postpartum hemorrhage. Massaging the fundus helps stimulate uterine contraction, which can help stop the bleeding.
B) Assess the woman's pulse and BP for signs of hypovolemic shock:
While it is important to monitor vital signs for signs of hypovolemic shock (e.g., increased heart rate, decreased blood pressure, and pale skin), this action would not be the first priority in managing a postpartum hemorrhage. The immediate focus should be on stopping the bleeding by addressing uterine atony. Hypovolemic shock assessment is important, but it comes after the initial steps of managing hemorrhage.
C) Call the woman's primary healthcare provider:
Calling the provider may be necessary if the bleeding does not stop after initial interventions. However, it should not be the first action. The nurse should first assess the uterus and attempt to stop the bleeding by massaging the fundus before calling the provider.
D) Begin an IV infusion of Ringer's lactate solution and administer oxytocin:
Starting an IV infusion and administering oxytocin may be part of the treatment for postpartum hemorrhage, but the first action should be to assess and manage the fundus. Oxytocin can help contract the uterus, but massaging the fundus is the immediate intervention. Intravenous fluids and medications should be initiated once the uterus is assessed and massaged, especially if bleeding persists.
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