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. 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.
Correct Answer is ["A","B","C","E"]
Explanation
A) The urethra, bladder, and urinary meatus are edematous:
Postpartum women often experience edema in the urethra, bladder, and urinary meatus due to the pressure exerted during delivery. This swelling can make it difficult for the woman to feel the urge to urinate, even when her bladder is full. Encouraging her to urinate every 2 hours helps prevent overdistension of the bladder, which can lead to urinary retention and other complications.
B) She has decreased sensitivity to fluid pressures after a vaginal birth:
After childbirth, especially a vaginal birth, the pelvic floor and surrounding tissues can be numb or less sensitive due to trauma, swelling, and the effects of anesthesia. This decreased sensitivity makes it harder for the woman to sense when she needs to urinate. Encouraging regular voiding even without the urge helps to prevent urinary retention, which is common in the immediate postpartum period.
C) At 12 hours postpartum, she will begin diuresing:
Diuresis, the process of excreting excess fluid retained during pregnancy, typically begins within 12 hours postpartum. This increased urine output can make it even more important for the mother to void regularly to prevent urinary retention. If the bladder is not emptied regularly, it can lead to discomfort and increase the risk of complications like bladder distention or infection.
D) There is no cause for concern as long as the patient urinates once per shift:
This is not true. A postpartum woman should void more frequently than once per shift (which is about every 8 hours). Urinating only once every shift can lead to urinary retention, bladder overdistension, and possible infection. The recommendation to urinate every 2 hours helps ensure proper bladder emptying and reduces the risk of complications.
E) A full bladder can lead to postpartum hemorrhage:
A full bladder can indeed contribute to postpartum hemorrhage (PPH). An overdistended bladder can displace the uterus, preventing it from contracting effectively after delivery. This can increase the risk of excessive bleeding. Regular voiding helps prevent bladder distention and supports uterine contraction, thereby reducing the risk of hemorrhage.
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