Nokea
The nurse is caring for an Rh-negative mother on the postpartum unit. What scenario indicates the need to administer RhoGAM to this patient?
- A. She has had one Rh-negative child and is pregnant with an Rh-negative child.
- B. She has had an Rh-positive infant and is pregnant with an Rh-positive fetus.
- C. She has had an O-negative child and is pregnant with a B-negative child.
- D. She is a primipara with an O-negative child.
Correct Answer: B
Rationale: Rationale:
1. Rh-negative mother with Rh-positive infant: During delivery, fetal blood can mix with maternal blood leading to sensitization.
2. Sensitization can cause the mother's immune system to produce antibodies against Rh antigen.
3. RhoGAM is administered to prevent antibody formation in Rh-negative mothers carrying Rh-positive infants.
Summary:
- A: Incorrect. No risk of sensitization as both child and fetus are Rh-negative.
- B: Correct. Rh-negative mother with Rh-positive infant at risk for sensitization.
- C: Incorrect. Rh factor mismatch between children doesn't require RhoGAM.
- D: Incorrect. Being primipara or child's blood type doesn't warrant RhoGAM administration.
You may also like to solve these questions
The nurse is advising parents about feeding their infant with phenylketonuria. What formula and/or diet should the nurse suggest?
- A. Lifelong high-protein diet
- B. A formula that is low in the amino acid leucine
- C. A soy-based formula
- D. Substitute Lofenalac for some protein foods
Correct Answer: D
Rationale: The correct answer is D, substitute Lofenalac for some protein foods. In phenylketonuria (PKU), individuals lack the enzyme to break down phenylalanine found in protein. Lofenalac is a special formula with low phenylalanine content, suitable for PKU patients. Lifelong high-protein diet (A) is incorrect as it would worsen the condition. A formula low in leucine (B) is not specific to PKU. Soy-based formula (C) still contains high levels of phenylalanine.
A 60-year-old client with a palpable mass to the right adnexa and family history of ovarian cancer is seen by the HCP. The nurse anticipates the order for which of the following laboratory results?
- A. CBC
- B. Blood glucose
- C. CA-125
- D. FSH and LH
Correct Answer: C
Rationale: The correct answer is C: CA-125. This tumor marker is used to assess for ovarian cancer in high-risk individuals. The client's age, palpable mass, and family history of ovarian cancer raise suspicion for malignancy. A CBC (choice A) and blood glucose (choice B) are not specific to ovarian cancer evaluation. FSH and LH (choice D) are hormone levels that do not directly assess for ovarian cancer. Therefore, CA-125 is the most appropriate lab test to anticipate in this scenario.
A 40-year-old woman has just been diagnosed with stage 2 breast cancer. Which of the following are common reactions? Select all that apply.
- A. Anxiety regarding changes in family reactions, body image, disability, and pain
- B. Concern about disruptions related to treatment
- C. Fear of death
- D. Decisional conflict related to controversies about treatment options
Correct Answer: A
Rationale: The correct answer is A. Anxiety is common due to the impact on family, body image, disability, and pain. Concern about treatment disruptions is valid but not as common as anxiety. Fear of death is a general fear but may not be as prominent as anxiety. Decisional conflict can occur but is more specific to treatment options rather than a common reaction.
When performing a breast assessment, the nurse is inspecting the woman’s skin for which of the following? Select all that apply.
- A. Color
- B. Thickening
- C. Size and symmetry
- D. Venous pattern
Correct Answer: A
Rationale: The correct answer is A: Color. When performing a breast assessment, inspecting the skin color is important to assess for any signs of redness, bruising, or discoloration which could indicate underlying issues. Thickening (B) is assessed through palpation, not inspection. Size and symmetry (C) is evaluated by comparing the breasts visually and through measurement. Venous pattern (D) is not typically a primary focus of skin inspection during a breast assessment.
A 58-year-old woman tells the nurse that she has started to experience pain during intercourse. The nurse should document that this woman is experiencing which of the following?
- A. Dyspnea
- B. Dyspareunia
- C. Dyspepsia
- D. Dysmenorrhea
Correct Answer: B
Rationale: The correct answer is B: Dyspareunia. Dyspareunia refers to pain during or after sexual intercourse. In this case, the woman is experiencing pain during intercourse, which aligns with the definition of dyspareunia. Dyspnea (A) is difficulty breathing, dyspepsia (C) is indigestion, and dysmenorrhea (D) is painful menstruation, none of which are related to pain during intercourse.