Nokea
The nurse administers RhoGAM to a postpartum client. Which of the following is the goal of the medication?
- A. Inhibit the mother's active immune response.
- B. Aggressively destroy the Rh antibodies produced by the mother.
- C. Prevent fetal cells from migrating throughout the mother's circulation.
- D. Change the maternal blood type to Rh-positive.
Correct Answer: A
Rationale: RhoGAM prevents sensitization.
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The nurse is assessing a newborn on admission to the newborn nursery. Which of the following findings should the nurse report to the neonatologist?
- A. Intracostal retractions.
- B. Caput succedaneum.
- C. Epstein's pearls.
- D. Harlequin sign.
Correct Answer: A
Rationale: Intracostal retractions indicate respiratory distress and require immediate attention.
What physiologic postpartum change occurs because the uterus shrinks in size, resulting in an increase in blood flow?
- A. Edema increases.
- B. Cardiac output increases.
- C. Temperature rises.
- D. Lochia increases.
Correct Answer: B
Rationale: The correct answer is B: Cardiac output increases. As the uterus shrinks in size postpartum, it stimulates an increase in blood flow to the area, leading to an increase in cardiac output to meet the demands. This is a normal physiologic response that helps to prevent excessive bleeding and promote healing. Edema increasing (A) is not directly related to the shrinking uterus. Temperature rising (C) is not a typical postpartum change due to uterine involution. Lochia increasing (D) is not a direct result of uterine shrinkage, but rather a normal discharge after childbirth.
If the rubella vaccine is indicated for a postpartum patient, which instructions should be provided?
- A. No specific instructions
- B. Drinking plenty of fluids to prevent fever
- C. Recommendation to stop breastfeeding for 24 hours after the injection
- D. Explanation of the risks of becoming pregnant within 28 days following injection
Correct Answer: D
Rationale: The correct answer is D because the rubella vaccine contains live virus and poses a risk to the fetus if the patient becomes pregnant within 28 days of receiving the vaccine. Providing instructions about the risks of pregnancy after vaccination is crucial to prevent potential harm to the fetus.
A: Incorrect - Specific instructions are necessary due to the live virus in the vaccine.
B: Incorrect - Drinking fluids does not address the specific risks associated with pregnancy after vaccination.
C: Incorrect - Stopping breastfeeding is not necessary after receiving the rubella vaccine.
Which site should the nurse use to assess the pulse of a baby?
- A. Carotid.
- B. Radial.
- C. Brachial.
- D. Pedal.
Correct Answer: C
Rationale: Brachial pulse is easily accessible in infants.
A couple has delivered a 28-week fetal demise. Which of the following nursing actions are appropriate to take?Select one that doesn't apply
- A. Swaddle the baby in a baby blanket.
- B. Discuss funeral options for the baby.
- C. Encourage the couple to try to get pregnant again in the near future.
- D. Ask the couple whether they would like to hold the baby.
Correct Answer: C
Rationale: Holding the baby and discussing funeral options support grieving.