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What is the primary reason for administering Rh immunoglobulin to an Rh-negative mother after delivery?
- A. To prevent maternal sensitization in future pregnancies
- B. To treat postpartum hemorrhage
- C. To reduce the risk of infection
- D. To boost maternal immune response
Correct Answer: A
Rationale: Rh immunoglobulin prevents maternal sensitization to Rh-positive blood.
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How would a patient who has taken Lamaze education respond when the health-care provider recommends breaking the bag of waters in early labor?
- A. As long as it will speed up my labor, that is fine.â€
- B. I trust whatever intervention you think is right.â€
- C. What are the risks and benefits of breaking my water right now?â€
- D. Will I be able to get an epidural after you break my water?â€
Correct Answer: C
Rationale: Lamaze encourages informed decision-making, prompting patients to ask about risks and benefits.
A nurse is preparing to administer methylergonovine 0.2 mg orally to a client who is 2 hr. postpartum and has a boggy uterus. For which of the following assessment findings should the nurse withhold the medication?
- A. Blood pressure 142/92 mm Hg
- B. Urine output 100 mL in hr.
- C. Pulse 58/min
- D. Respiratory rate 14/min
Correct Answer: A
Rationale: Methylergonovine is a medication used to help contract the uterus and control postpartum hemorrhage. One of its side effects is vasoconstriction, which can lead to increased blood pressure. The client's blood pressure of 142/92 mm Hg is elevated, and administering methylergonovine could further increase the blood pressure, potentially causing harm to the client. It is important to withhold the medication in this situation to prevent worsening of hypertension. The other assessment findings are within normal ranges and do not contraindicate the administration of methylergonovine.
A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?
- A. Palpate the client's uterine fundus.
- B. Assist the client on a bedpan to urinate.
- C. Prepare to administer oxytocic medication.
- D. Increase the client's fluid intake.
Correct Answer: A
Rationale: The priority nursing intervention in this situation is to palpate the client's uterine fundus. Saturating two perineal pads with blood in a 30-minute period after childbirth is indicative of excessive postpartum bleeding, also known as postpartum hemorrhage (PPH). Palpating the uterine fundus helps the nurse assess for uterine atony, a common cause of PPH. If the fundus is boggy or not firm, it indicates that the uterus is not contracting effectively to control bleeding, which can lead to further complications if not addressed promptly. Once uterine atony is identified, other interventions such as administering oxytocic medications can be initiated to help the uterus contract and control bleeding.
Three hours after birth, a newborn of a mother with diabetes becomes jittery, has weak, high- pitched cry , and exhibits irregular respirations. The nurse recognizes that these signs are often associated with:
- A. Hypovolemia
- B. Hypocalcemia
- C. Hypoglycemia
- D. Hyperglycemia
Correct Answer: C
Rationale: The signs described in the scenario - jitteriness, weak high-pitched cry, irregular respirations - are indicative of hypoglycemia in a newborn. Babies born to mothers with diabetes are at risk for hypoglycemia due to their exposure to high blood sugar levels in utero. After birth, when the baby is separated from the mother's blood supply, their own insulin production may lead to a sudden drop in blood glucose levels.
A client reports experiencing painless contractions at 32 weeks' gestation. What should the nurse explain?
- A. These are Braxton Hicks contractions and are normal.
- B. This is a sign of preterm labor.
- C. This indicates cervical dilation.
- D. This requires immediate hospitalization.
Correct Answer: A
Rationale: Braxton Hicks contractions are common in the third trimester and typically do not signify labor.