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 B
Explanation
Choice A rationale
Diazepam is a benzodiazepine used primarily for anxiety, muscle spasms, and seizures. It is not recommended for opioid use disorder during pregnancy due to potential risks to the fetus, including withdrawal symptoms and developmental issues.
Choice B rationale
Methadone is a long-acting opioid agonist used to treat opioid use disorder. It helps reduce withdrawal symptoms and cravings without producing the euphoria associated with opioid abuse. Methadone is considered safe for use during pregnancy and can improve maternal and fetal outcomes.
Choice C rationale
Naloxone is an opioid antagonist used to reverse opioid overdose. While it is crucial to have naloxone readily available for individuals with opioid use disorder to prevent overdose deaths, it is not a primary treatment for opioid use disorder during pregnancy.
Choice D rationale
Buprenorphine is a partial opioid agonist used to treat opioid use disorder. It is considered safe for use during pregnancy and can reduce withdrawal symptoms and cravings. However, methadone is often preferred due to its longer history of use and more extensive research on its safety during pregnancy.
Correct Answer is B
Explanation
Choice A rationale
The statement about the partner wanting to help but not planning for the baby indicates a lack of acceptance and preparation for the pregnancy. It suggests that the adolescent and their partner may not have fully embraced the reality of the pregnancy.
Choice B rationale
Missing soda but acknowledging that it is better for the baby indicates that the adolescent is making sacrifices and changes for the benefit of the baby. This behavior reflects acceptance of the pregnancy and a willingness to prioritize the baby’s health.
Choice C rationale
Being upset about having to quit school when the baby comes indicates that the adolescent is struggling with the impact of the pregnancy on their life plans. This statement suggests a lack of acceptance and difficulty in adjusting to the pregnancy.
Choice D rationale
Expecting the parents to raise the baby due to being young indicates a lack of acceptance and responsibility for the pregnancy. It suggests that the adolescent may not be fully prepared to take on the role of a parent.