A nurse is planning to administer Rh(D) immune globulin to a client who is postpartum.Which of the following actions should the nurse take?
Verify that the newborn is Rh-negative.
Verify that the client’s Coombs test is positive.
Administer the medication within 72 hours after birth.
Administer the medication into the client’s abdomen.
The Correct Answer is C
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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is D
Explanation
Choice A rationale
Using a breast pump can help maintain milk supply if the client plans to return to work, but it does not directly prevent mastitis.
Choice B rationale
Covering the breasts immediately after feedings is not necessary and does not prevent mastitis. Proper hygiene and feeding techniques are more important.
Choice C rationale
Wearing an underwire bra can restrict milk flow and increase the risk of mastitis. A well-fitting, non-restrictive bra is recommended.
Choice D rationale
Washing nipples with soap and water daily can cause dryness and irritation, increasing the risk of mastitis. It is better to clean the nipples with water only and ensure proper latch and feeding techniques. .
Correct Answer is B
Explanation
Choice A rationale
Limiting the client’s daily fluid intake is not recommended. Adequate hydration is important for clients with mastitis to help clear the infection and maintain milk supply.
Choice B rationale
Encouraging the client to continue to breastfeed is recommended. Breastfeeding helps to empty the breasts and reduce milk stasis, which can alleviate symptoms of mastitis.
Choice C rationale
Preparing the client for an abdominal sonogram is not relevant to the management of mastitis. Mastitis is typically diagnosed based on clinical symptoms and physical examination.
Choice D rationale
Encouraging the client to wear a bra that is loose fitting is not recommended. A well-fitting, supportive bra can help to reduce discomfort and support the breasts during mastitis.