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It is determined that a client's blood Rh is negative and her partner's is positive. To help prevent Rh isoimmunization, the nurse would expect to administer Rho(D) immune globulin at which time?
- A. 24 hours before delivery and 24 hours after delivery
- B. In the first trimester and within 2 hours of delivery
- C. At 28 weeks gestation and again within 72 hours after delivery
- D. At 32 weeks gestation and immediately before discharge
Correct Answer: C
Rationale: Rho(D) immune globulin at 28 weeks and within 72 hours post-delivery prevents Rh isoimmunization by neutralizing fetal Rh-positive cells. Earlier or later timing risks ineffective prevention or antibody formation.
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It is determined that a client's blood Rh is negative and her partner's is positive. To help prevent Rh isoimmunization, the nurse would expect to administer Rho(D) immune globulin at which time?
- A. 24 hours before delivery and 24 hours after delivery
- B. In the first trimester and within 2 hours of delivery
- C. At 28 weeks gestation and again within 72 hours after delivery
- D. At 32 weeks gestation and immediately before discharge
Correct Answer: C
Rationale: Rho(D) immune globulin at 28 weeks and within 72 hours post-delivery prevents Rh isoimmunization effectively. Other schedules miss critical windows for blocking maternal antibody response.
Upon entering the room of a client who has had a spontaneous abortion, the nurse observes the client crying. Which response by the nurse would be most appropriate?
- A. I'm sorry you lost your baby.
- B. Why are you crying?
- C. Will a pill help your pain?
- D. A baby still wasn't formed in your womb.
Correct Answer: A
Rationale: Saying 'I'm sorry you lost your baby' acknowledges the client's emotional loss empathetically. Asking why she's crying invalidates her feelings, focusing on physical pain ignores emotional needs, and claiming the baby wasn't formed is inaccurate and insensitive, as miscarriage involves loss at any stage.
A client comes to the prenatal clinic for her first visit. When determining the client's estimated due date, the nurse understands which method is the most accurate.
- A. Nagele's rule
- B. Ultrasound
- C. Gestation wheel
- D. Birth calculator
Correct Answer: B
Rationale: Ultrasound in the first trimester measures fetal size accurately for due date estimation, unlike Nagele's rule, gestation wheel, or calculators, which rely on less precise menstrual data or assumptions.
When assessing a woman in her first trimester, which emotional response would the nurse most likely expect to find?
- A. Ambivalence
- B. Emotional lability
- C. Introversion
- D. Acceptance
Correct Answer: B
Rationale: Emotional lability is typical in the first trimester from hormonal changes causing irritability or crying. Ambivalence is less common unless conflicted, introversion isn't pregnancy-specific, and acceptance grows over time.
A woman comes to the prenatal clinic suspecting that she is pregnant, and assessment reveals probable signs of pregnancy. Which findings would the nurse most likely assess? Select all that apply.
- A. Ultrasound visualization of the fetus
- B. Softening of the cervix
- C. Positive pregnancy test
- D. Absence of menstruation
- E. Ballottement
- F. Auscultation of a fetal heart beat
Correct Answer: B,C,D,E
Rationale: Probable signs include softening of the cervix (Goodell's), positive pregnancy test (hCG), amenorrhea, and ballottement (fetal rebound). Ultrasound and fetal heartbeat are positive signs, confirming pregnancy definitively.