A nurse in a provider’s office is collecting data from a client who is at 34 weeks of gestation and reports having a sudden gush of vaginal fluid.Which of the following manifestations is the priority?
Amniotic fluid with meconium noted.
Maternal temperature 38.3°C (101°F).
Foul smelling vaginal discharge.
Fetal heart tones 98/min.
The Correct Answer is D
Choice A rationale
Amniotic fluid with meconium noted can indicate fetal distress, but it is not the most immediate priority compared to fetal heart tones.
Choice B rationale
A maternal temperature of 38.3°C (101°F) can indicate infection, but it is not the most immediate priority compared to fetal heart tones.
Choice C rationale
Foul-smelling vaginal discharge can indicate infection, but it is not the most immediate priority compared to fetal heart tones.
Choice D rationale
Fetal heart tones of 98/min indicate fetal bradycardia, which is a sign of fetal distress and requires immediate intervention to ensure the well-being of the fetus.
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Correct Answer is C
Explanation
Choice A rationale
Verifying that the newborn is Rh-negative is not necessary for administering Rh(D) immune globulin. The medication is given to Rh-negative mothers to prevent Rh sensitization, regardless of the newborn’s Rh status.
Choice B rationale
A positive Coombs test indicates that the mother has already been sensitized to Rh-positive blood cells, making Rh(D) immune globulin ineffective in preventing sensitization.
Choice C rationale
Administering Rh(D) immune globulin within 72 hours after birth is crucial to prevent Rh sensitization in future pregnancies. This timing ensures that the mother’s immune system does not produce antibodies against Rh-positive blood cells.
Choice D rationale
Rh(D) immune globulin is typically administered intramuscularly, not into the abdomen. The preferred sites are the deltoid muscle or the anterolateral aspect of the thigh.
Correct Answer is A
Explanation
Choice A rationale
Placing the retainer clip at the level of the baby’s armpits is the correct position for the clip. This ensures that the harness straps are positioned correctly over the baby’s shoulders, providing optimal protection in the event of a crash.
Choice B rationale
Placing the baby in the car seat at a 90-degree angle is incorrect. Newborns should be placed in a rear-facing car seat at an angle of approximately 45 degrees to ensure their airway remains open and to provide proper support for their head and neck.
Choice C rationale
Turning the car seat to face forward when the baby weighs 15 pounds is not recommended. Babies should remain in a rear-facing car seat until they reach the maximum weight or height limit specified by the car seat manufacturer, typically around 2 years of age.
Choice D rationale
Placing a thick, soft pad behind the baby’s back is not recommended. Additional padding can interfere with the proper fit of the harness and reduce the effectiveness of the car seat in protecting the baby during a crash.