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 B
Explanation
Choice A rationale
Encouraging the child to dress in clothing that suits her sexual maturity level is not an appropriate approach for managing precocious puberty. The goal of treatment with LHRH is to delay further development until the appropriate age, allowing the child to dress according to her chronological age rather than her advanced physical maturity.
Choice B rationale
The purpose of LHRH therapy is to regulate and normalize the child's hormonal levels, which can slow or stop the progression of precocious puberty. As the therapy takes effect, differences in sexual maturity between the child and her peers should diminish over time, allowing her development to align more closely with her age group.
Choice C rationale
LHRH treatment for precocious puberty is typically not lifelong. It is used to delay puberty until a more appropriate age. Once treatment is stopped, the child's body will resume normal pubertal development. Parents should understand that the therapy is temporary and aimed at managing early onset puberty.
Choice D rationale
Starting the child on birth control pills is not a standard treatment for precocious puberty. The goal of LHRH therapy is to manage hormonal levels to delay puberty, not to prevent pregnancy. Birth control pills are not necessary and do not address the underlying condition being treated with LHRH therapy. .
Correct Answer is D
Explanation
Choice A rationale
Typing and crossmatching for a possible transfusion is not the immediate priority for a child with hemophilia who has a swollen knee. While a transfusion might be necessary if there is significant bleeding, initial management should focus on controlling the bleeding and minimizing joint damage.
Choice B rationale
Initiating an IV site and beginning infusing normal saline is not the first action to take in this scenario. While IV access might be needed later, immediate measures should focus on controlling bleeding and reducing swelling to prevent further damage to the knee joint.
Choice C rationale
Monitoring the child's vital signs frequently is important, but it is not the first action to take. The priority is to control the bleeding and reduce the swelling, which are the immediate concerns in this situation.
Choice D rationale
Applying an ice pack and compression dressing to the knee is the first action to take. This helps to control bleeding, reduce swelling, and minimize joint damage. This is a crucial step in managing hemophilia-related injuries and should be done immediately upon recognizing a swollen joint.
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