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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?
- A. Verify that the newborn is Rh-negative.
- B. Verify that the client's Coombs test is positive.
- C. Administer the medication into the client's abdomen.
- D. Administer the medication within 72 hours after birth.
Correct Answer: D
Rationale: Administering Rh(D) immune globulin within 72 hours prevents Rh sensitization in Rh-negative mothers, crucial for future pregnancies.
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Nurses' Notes (Postpartum Assessment) 1200: The client successfully delivered a viable newborn via vaginal delivery. 1300: The client reports feeling tired and anxious. Assessment reveals the fundus is deviated to the left, boggy, and located 1 cm above the umbilicus. The perineal pad is saturated with lochia rubra, indicating excessive bleeding. The client reports an inability to ambulate to the bathroom due to residual numbness from the labor epidural. Pain is reported as 0 on a scale of 0 to 10. Fundal massage performed during assessment has yielded no improvement in uterine tone. A nurse is caring for a 36-year-old female client in the labor and delivery unit at 39 weeks of gestation admitted for evaluation of postpartum bleeding following a vaginal delivery.
Select the 2 interventions the nurse should perform immediately.
- A. Weigh the client’s perineal pad.
- B. Insert a straight catheter for the client.
- C. Administer methylergonovine 0.2 mg IM.
- D. Draw a complete blood count.
- E. Apply oxygen via nasal cannula.
Correct Answer: B,C
Rationale: Inserting a catheter empties the bladder, aiding uterine contraction; methylergonovine stimulates contractions to reduce bleeding from a boggy uterus.
A nurse in an antepartum unit is assisting with the care of a client who has preeclampsia and is receiving IV magnesium sulfate therapy.
For which of the following adverse effects should the nurse monitor and report to the provider?
- A. Tachypnea.
- B. Hyporeflexia.
- C. Agitation.
- D. Polyuria.
Correct Answer: B
Rationale: Hyporeflexia indicates magnesium sulfate toxicity, a serious adverse effect requiring immediate reporting to prevent respiratory or cardiac issues.
A nurse is caring for a 2-day-old newborn who is undergoing phototherapy for treatment of hyperbilirubinemia.
Which of the following actions should the nurse take?
- A. Provide additional hydration by offering glucose water.
- B. Apply a water-based lotion to the newborn's skin every 4 hours.
- C. Remove the newborn from phototherapy every 2 hours for breastfeeding.
- D. Monitor the newborn's heart rate every 2 hours.
Correct Answer: C
Rationale: Removing the newborn for breastfeeding every 2 hours ensures nutrition and bonding without significantly disrupting phototherapy.
Nurses' Notes: The newborn is lying in a bassinet, lightly swaddled. Jitteriness observed when disturbed, weak cry, mottled extremities, mild acrocyanosis. Respirations rapid but unlabored. No lethargy, no feedings since birth. Vital Signs: Heart rate: 156/min, Respiratory rate: 64/min, Temperature: 36.1°C (97.0°F), Oxygen saturation: 96% on room air, Blood glucose level: 30 mg/dL.
Complete the diagram by dragging from the choices below to specify: Condition, Actions to Take, Parameters to Monitor (2 Correct). Condition Choices: A. Hypoglycemia, B. Congenital heart defect, C. Neonatal sepsis, D. Neonatal abstinence syndrome. Actions: A. Obtain a capillary blood glucose reading, B. Feed the newborn immediately with breastmilk or formula, C. Administer IV glucose as prescribed, D. Initiate phototherapy, E. Place under a radiant warmer. Parameters: A. Blood glucose levels, B. Respiratory effort, C. Serum bilirubin levels, D. Skin integrity, E. Oxygen saturation.
- A. Hypoglycemia
- B. Obtain a capillary blood glucose reading
- C. Feed the newborn immediately with breastmilk or formula
- D. Blood glucose levels
- E. Respiratory effort
Correct Answer: A,A,B,A,B
Rationale: Low glucose (30 mg/dL) and jitteriness indicate hypoglycemia; feeding and glucose checks address it; glucose and respiratory effort monitor progress.
A nurse is reinforcing teaching with a client about laboratory testing during pregnancy.
Which of the following statements should the nurse include in the teaching?
- A. A multiple marker screening will be performed to identify neural tube defects.
- B. A glucose tolerance test will be performed to predict hyperglycemia in your baby.
- C. A Papanicolaou test will be performed to detect the presence of herpes simplex type 1.
- D. A group B streptococcus screening will be performed to determine the presence of STIs.
Correct Answer: A
Rationale: A multiple marker screening detects neural tube defects and chromosomal abnormalities, typically performed between 15-20 weeks of gestation.