The laboratory results for a postpartum woman are as follows:
blood type: A +
rubella: non-immune
hematocrit: 30%
GBS: negative
How would the nurse best interpret these data?
A rubella injection is advised
A blood transfusion is advised
The nurse should contact the provider for an antibiotic order an
RhoGAM injection should be administered within 72 hours
The Correct Answer is A
A) A rubella injection is advised:
Since the rubella titer is non-immune, the woman is not protected against rubella, which is important to address during the postpartum period. The rubella vaccine is typically given to women who are non-immune to rubella after childbirth, but it is contraindicated during pregnancy because it is a live vaccine. The best action in this case would be to administer the rubella vaccine to the postpartum woman before discharge, with instructions to avoid becoming pregnant for at least 28 days after vaccination to prevent harm to a future fetus.
B) A blood transfusion is advised:
The hematocrit of 30% indicates that the woman has mild anemia, but it does not require immediate intervention like a blood transfusion. Normal hematocrit levels for postpartum women typically range between 32% and 42%. A transfusion would be indicated if the hematocrit were much lower (usually below 20-25%) or if there were symptoms of significant blood loss, which are not indicated in this case.
C) The nurse should contact the provider for an antibiotic order:
There is no indication from the provided laboratory results or the scenario that the woman requires antibiotics. Group B Streptococcus (GBS) was negative, which eliminates the need for prophylactic antibiotics. There is no mention of any infection risk requiring an antibiotic prescription, and since her GBS result is negative, antibiotics are not warranted.
D) RhoGAM injection should be administered within 72 hours:
RhoGAM (Rh immunoglobulin) is typically administered to a woman with Rh-negative blood who has given birth to an Rh-positive baby to prevent Rh sensitization in future pregnancies. In this case, the woman has an Rh-positive blood type (A+), so she does not need RhoGAM. RhoGAM would only be necessary if the woman had an Rh-negative blood type, which she does not.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ask the patient to empty her bladder:
A boggy uterus that is displaced above and to the right of the umbilicus is often a sign of bladder distention. A full bladder can push the uterus out of its normal position, preventing it from contracting properly and leading to uterine atony. Asking the patient to empty her bladder is the most appropriate initial action, as it can help reposition the uterus and promote uterine contraction, reducing the risk of postpartum hemorrhage.
B. Notify the MD about an impending hemorrhage:
While a boggy, displaced uterus can be a sign of uterine atony and the risk of hemorrhage, the first action should be to address the likely cause—bladder distention. Emptying the bladder may resolve the issue and help the uterus contract. Notifying the healthcare provider may be necessary later if other complications arise, but it’s not the most immediate intervention in this situation.
C. Assess blood pressure and pulse:
Assessing vital signs, including blood pressure and pulse, is important for monitoring the patient’s overall condition, especially if there is suspicion of hemorrhage. However, this is a secondary action after addressing the immediate problem (bladder distention). The priority is to help the uterus contract and reposition it before worrying about potential hemorrhage.
D. Evaluate lochia:
Evaluating lochia is an important step in assessing the patient’s postpartum status, especially to monitor for excessive bleeding. However, the immediate concern in this case is the displaced uterus, which is most likely due to bladder distention. The most effective action would be to address the bladder fullness first. After addressing this, lochia should be assessed to monitor for bleeding.
Correct Answer is E
Explanation
A) Bulb syringe in crib:
While a bulb syringe can be useful for clearing the infant’s airway in case of respiratory distress, keeping it in the crib is not an optimal safety practice. The syringe should be readily available but not within reach of the infant, as it could be a choking hazard if mishandled. Ideally, it should be stored in an easily accessible area but not within the crib.
B) Secure hugs tag on and alarms activated:
Ensuring that the infant has a security tag (often referred to as a "Hugs" tag) that is properly placed and that alarms are activated is an important safety measure to prevent infant abductions. Hospitals typically use electronic security systems that alert staff if the infant is removed from the designated area without proper authorization. This intervention is essential for maintaining safety in the hospital setting.
C) ID bands match with mom's ID bands:
It is critical that the infant's ID band matches the mother's ID band. This helps prevent any mix-up or baby swap and ensures that the infant is properly identified at all times. Regular checks should be made to verify that the bands match and remain secure throughout the hospital stay.
D) Infant on their back to sleep:
Placing the infant on their back to sleep is a key guideline for reducing the risk of Sudden Infant Death Syndrome (SIDS). This position has been proven to be the safest for infants and is a crucial practice for their well-being. Educating parents and caregivers about safe sleep practices is vital for infant safety.
E) All of the above:
All of these practices are part of a comprehensive safety plan for the infant. Ensuring that the infant is safely secured with proper identification, preventing any risk of abduction, promoting safe sleep practices, and ensuring that airway equipment is available are all essential measures in maintaining the safety of the newborn. Therefore, the correct response is "All of the above."
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