The nurse is caring for a primigravida client who delivered vaginally 48-hours ago.The client's laboratory results are: hemoglobin 12 g/dL (125 g/L), hematocrit 34% (0.34 volume fraction), hepatitis B surface antigen negative, rubella non-immune, group B Streptococcus negative. Which prescription should the nurse prepare to administer?
Blood transfusion.
Rubella vaccination.
Penicillin G potassium.
Hepatitis B immunoglobulin.
The Correct Answer is B
Choice A rationale
The client has a hemoglobin level of 12 g/dL and a hematocrit of 34%, which are within normal ranges for a postpartum woman. A blood transfusion is typically indicated for severe anemia or significant blood loss, neither of which is suggested by these lab results. Therefore, a blood transfusion is not warranted in this case.
Choice B rationale
Rubella vaccination is indicated for a client who is non-immune to rubella, as indicated by the laboratory results. Rubella vaccination is important to protect the client from contracting rubella in future pregnancies, which can cause serious congenital defects. Since the client is not currently pregnant and not immune, vaccination can be safely administered postpartum to prevent future rubella infections.
Choice C rationale
Penicillin G potassium is an antibiotic that might be used for a client who is group B Streptococcus positive to prevent neonatal infection during delivery. However, this client is group B Streptococcus negative, so there is no indication for this antibiotic. There is no need to administer Penicillin G potassium in this scenario.
Choice D rationale
Hepatitis B immunoglobulin is used for newborns of mothers who are hepatitis B surface antigen positive to prevent perinatal transmission of the virus. Since the client's lab results indicate she is hepatitis B surface antigen negative, there is no need for Hepatitis B immunoglobulin. The client and her newborn are not at risk of hepatitis B transmission, so this intervention is not required. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A sore throat, often due to Streptococcus pyogenes, is a significant precursor to acute rheumatic fever. The body’s immune response to the infection can attack its own tissues, leading to rheumatic heart disease if untreated.
Choice B rationale
Influenza is a viral infection and does not typically lead to acute rheumatic fever. While it can cause significant illness, its mechanism and sequelae are unrelated to those of rheumatic fever.
Choice C rationale
Chickenpox, caused by the varicella-zoster virus, presents with distinct symptoms like a vesicular rash and is not linked to rheumatic fever. It primarily affects the skin and nervous system, not the heart.
Choice D rationale
Mumps, a viral infection, mainly impacts the salivary glands and sometimes the pancreas and testes but is not associated with rheumatic fever. Its pathology differs from the immune-mediated damage seen in rheumatic fever.
Correct Answer is B
Explanation
Choice A rationale
Rooting is a reflex that helps a baby find and latch onto the breast or bottle for feeding. While the rooting reflex may diminish as the baby grows, it is not the primary indicator for introducing solid foods. Other developmental milestones are more relevant for this transition.
Choice B rationale
When a baby starts opening their mouth in response to the sight or smell of food, it indicates a readiness to try solid foods. This behavior shows that the baby is interested in and capable of learning to eat from a spoon, which is a key step in the introduction of solids.
Choice C rationale
Awakening once for nighttime feedings is common for infants and does not necessarily indicate readiness for solid foods. Nighttime awakenings can occur for various reasons, including hunger, but other developmental signs should be considered for introducing solids.
Choice D rationale
Giving up a bottle for a cup is a milestone that typically occurs later in infancy or toddlerhood. It is not directly related to the introduction of solid foods, which generally begins around 4 to 6 months of age based on the child's developmental readiness and interest in food.
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