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.
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Correct Answer is C
Explanation
Choice A rationale
A Papanicolaou test, commonly known as a Pap smear, is used to detect cervical cancer and precancerous changes in the cervix. It does not detect herpes simplex type 1. Herpes simplex virus (HSV) testing is typically done through a swab of the lesion or blood tests to detect antibodies.
Choice B rationale
A glucose tolerance test is performed during pregnancy to screen for gestational diabetes, not to predict hyperglycemia in the baby. This test helps identify how well the mother’s body is managing glucose and ensures that both mother and baby remain healthy during pregnancy.
Choice C rationale
A multiple marker screening, also known as a triple or quad screen, is performed during pregnancy to identify potential neural tube defects, such as spina bifida, and chromosomal abnormalities like Down syndrome. This test measures specific substances in the mother’s blood to assess the risk of these conditions.
Choice D rationale
Group B streptococcus (GBS) screening is performed to detect the presence of GBS bacteria in the mother’s body, not to determine the presence of sexually transmitted infections (STIs). GBS can cause serious infections in newborns, so it is important to identify and treat it before delivery.
Correct Answer is A
Explanation
Choice A rationale
A positive Babinski reflex is characterized by the fanning out of the toes and the upward movement of the big toe when the sole of the foot is stroked. This reflex is normal in infants up to 2 years old and indicates an immature central nervous system. The presence of this reflex in older children or adults can indicate neurological issues.
Choice B rationale
Curling in of the toes when the sole of the foot is stroked is indicative of the plantar grasp reflex, not the Babinski reflex. The plantar grasp reflex is a different neurological response and does not indicate the same neurological development as the Babinski reflex.
Choice C rationale
No response when the sole of the foot is stroked could indicate a lack of neurological response or an issue with the sensory or motor pathways. This is not characteristic of a positive Babinski reflex and could be a sign of neurological impairment.
Choice D rationale
The big toe bending down when the sole of the foot is stroked is a normal response in older children and adults, known as the plantar reflex. This response indicates a mature central nervous system and is not characteristic of a positive Babinski reflex in infants.