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 ["0.5"]
Explanation
Given:
Desired dose: Vitamin K 0.5 mg IM
Available concentration: Vitamin K 1 mg/1 mL
To find:
Volume to administer (in mL)
Step 1: Set up the proportion
We can use the following proportion to solve the problem:
(Desired dose) / (Available concentration) = Volume to administer
Step 2: Substitute the values
Plugging in the given values, we get:
(0.5 mg) / (1 mg/1 mL) = Volume to administer
Step 3: Simplify
To simplify, we can invert the denominator and multiply:
(0.5 mg) x (1 mL / 1 mg) = Volume to administer
The "mg" units cancel out, leaving us with:
(0.5 x 1 mL) / 1 = Volume to administer
Step 4: Calculate
Performing the multiplication and division, we get:
0.5 mL / 1 = Volume to administer
0.5 mLVolume to administer
Correct Answer is A
Explanation
A) "Keep umbilical cord dry and above the level of the diaper."
The umbilical cord stump should be kept clean, dry, and exposed to air as much as possible to prevent infection. The diaper should be folded below the stump to ensure that it remains dry and doesn’t rub against it, which can lead to irritation or infection.
B) "Baby will need to breastfeed every hour."
Newborns typically breastfeed every 2 to 3 hours, not necessarily every hour. The exact frequency may vary based on the baby's hunger cues. Overstating the frequency of feedings may cause undue anxiety for parents, as newborns may not feed this frequently.
C) "Be sure to always wrap baby in 2 blankets when going outside."
Overbundling can lead to overheating. Newborns should be dressed in appropriate layers for the weather, with one layer more than an adult would wear. The use of two blankets may not be necessary unless it is extremely cold. The key is ensuring the baby is comfortably warm, not overheated.
D) "Limit the amount of time baby is skin to skin with parents."
Skin-to-skin contact is beneficial for newborns, especially in the early days after birth. It promotes bonding, stabilizes the baby’s body temperature, supports breastfeeding, and helps with the baby’s physiological stability. There is no need to limit skin-to-skin contact unless medically contraindicated.
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