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 B
Explanation
Choice A rationale
There is no need to fast before a nonstress test. The test measures the fetal heart rate in response to fetal movements and does not require any dietary restrictions.
Choice B rationale
During a nonstress test, the client will press a button whenever they feel the baby move. This helps correlate fetal movements with heart rate changes.
Choice C rationale
The client is not required to lie flat on their back for the duration of the test. They can be in a semi-reclined position to ensure comfort and avoid supine hypotensive syndrome.
Choice D rationale
Medication to stimulate contractions is not used during a nonstress test. This is done during a contraction stress test, which is a different procedure.
Correct Answer is A
Explanation
Choice A rationale
Taking a break and walking at least once every hour during long trips helps improve circulation and reduces the risk of blood clots, which is particularly important during pregnancy.
Choice B rationale
Wearing the shoulder harness snug across the stomach is incorrect. The shoulder harness should be worn across the chest and between the breasts to avoid pressure on the abdomen.
Choice C rationale
Positioning the lap belt across the navel is incorrect. The lap belt should be placed under the belly, across the hips and pelvic bone, to avoid pressure on the uterus.
Choice D rationale
Moving the car seat forward, close to the steering wheel, is not recommended. Pregnant women should maintain a safe distance from the steering wheel to avoid injury in case of an accident.