When should Rhogam be administered to a pregnant woman who is Rh-positive?
Rhogam is not indicated for this patient.
At 28 weeks of gestation.
During labor if the baby is Rh-positive.
At the beginning of the second trimester.
The Correct Answer is A
Choice A rationale
Rhogam, an immunoglobulin, is administered to Rh-negative pregnant women to prevent the development of antibodies against Rh-positive fetal blood cells. It works by destroying any fetal red blood cells that may have entered the maternal circulation, thereby preventing the mother's immune system from becoming sensitized. Since the patient is Rh-positive, her body will not produce antibodies against her own Rh-positive red blood cells or an Rh-positive fetus, making Rhogam administration unnecessary.
Choice B rationale
Administration of Rhogam at 28 weeks of gestation is the standard prophylactic protocol for Rh-negative pregnant women. This timing is chosen because it's a period of peak risk for fetomaternal hemorrhage. This choice is incorrect for this patient because she is Rh-positive, and thus is not at risk for Rh isoimmunization, making the medication unnecessary.
Choice C rationale
Administering Rhogam during labor is a reactive measure taken when an Rh-negative mother is giving birth to an Rh-positive baby. The goal is to prevent sensitization from the blood mixing during delivery. This choice is incorrect for this patient since she is Rh-positive and does not require the medication at all, regardless of the baby's Rh status.
Choice D rationale
The beginning of the second trimester is not a standard administration time for prophylactic Rhogam. The typical timing for routine administration is around 28 weeks of gestation. This choice is incorrect for this patient because she is Rh-positive, and therefore does not need Rhogam at any point during her pregnancy. *.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While nuts and legumes are good sources of non-dairy calcium, yogurt is a dairy product. The client is specifically asking for a list of non-dairy foods. Therefore, this choice is incorrect because it includes a dairy product.
Choice B rationale
Both yogurt and milk are dairy products, and therefore do not align with the client's request for non-dairy calcium sources. Starchy vegetables do contain some calcium, but this choice is incorrect due to the inclusion of dairy.
Choice C rationale
Nuts, legumes, and starchy vegetables all contain some calcium. However, this choice does not represent the most calcium-rich non-dairy options available, and other choices provide a more complete and accurate list of excellent non-dairy sources.
Choice D rationale
Fortified orange juice, salmon with bones (e.g., canned salmon), and collard greens are all excellent sources of non-dairy calcium. This combination provides a variety of food types that can be incorporated into the diet to meet increased calcium needs during pregnancy. *.
Correct Answer is A
Explanation
Choice A rationale
The observed fetal heart rate pattern, with a gradual decrease that mirrors the peak of the contraction, is indicative of a late deceleration. This pattern is a sign of uteroplacental insufficiency, where the fetus is not receiving adequate oxygen during contractions. Repositioning the patient and decreasing oxytocin are the priority actions to improve oxygenation and reduce uterine hyperstimulation.
Choice B rationale
Notifying the provider to come for delivery is not the immediate priority. While the provider needs to be informed, the nurse's first action is to intervene with measures to correct the issue and improve fetal oxygenation. The goal is to stabilize the fetal heart rate pattern before considering delivery options, which may not be necessary if the pattern resolves.
Choice C rationale
Assessing for perineal pressure or the urge to push is a routine part of labor assessment but is not the priority action for a late deceleration. This action is relevant for assessing for imminent birth, whereas the primary concern here is fetal well-being and correcting the underlying cause of the heart rate pattern.
Choice D rationale
Increasing oxytocin is contraindicated. Oxytocin stimulates uterine contractions, which in this case are causing the uteroplacental insufficiency. Increasing the dose would exacerbate the problem, further compromising fetal oxygenation and worsening the late decelerations. The appropriate action is to decrease or discontinue the oxytocin
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