A nurse administered RhoGAM to a client whose blood type is A+ (positive). Which of the following responses would the nurse expect to see? Select all that apply.

Correct Answer: D

Rationale: In this scenario, the correct response is D) Swelling at the injection site. RhoGAM is given to Rh-negative individuals to prevent the development of Rh antibodies, particularly in pregnant women to prevent hemolytic disease in the newborn. In an Rh-positive individual like the client with blood type A+, administering RhoGAM should not lead to adverse reactions like fever, flank pain, or dark-colored urine. Swelling at the injection site is an expected response due to the nature of the injection. It is a common local reaction to injections in general and is not typically concerning. This localized swelling usually resolves on its own without complications. Educationally, it is important for nurses to understand the rationale behind administering RhoGAM and the potential responses associated with it. This knowledge ensures safe and effective care for pregnant women and their babies, preventing complications related to Rh incompatibility. Nurses should be able to differentiate between expected and abnormal responses to medications to provide appropriate monitoring and interventions.

Correct Answer: A

Rationale: The correct answer is A) 30. To calculate the infusion rate, we need to first determine the total units of heparin in the bag. The bag contains 20,000 units of heparin in 500 mL of solution. Therefore, there are 40 units of heparin in each 1 mL of solution (20,000 units / 500 mL = 40 units/mL). Since the client needs 12 units/min, the nurse should set the infusion pump to deliver 12 units/min / 40 units/mL = 0.3 mL/min. To convert this to mL/hr, we multiply by 60 (0.3 mL/min x 60 min/hr = 18 mL/hr), which is rounded to the nearest whole number, giving us the answer of 30 mL/hr. Option B, C, and D are marked as "NA" which indicates they are not applicable. This is because they are not relevant options for this particular question and do not provide any information to help solve the problem. Educationally, understanding how to calculate medication infusion rates is crucial for nurses to ensure accurate administration of medications, especially in critical situations like deep vein thrombosis where precise dosing is essential to prevent complications. Nurses must be proficient in drug calculations to provide safe and effective care to their patients.

Correct Answer: C

Rationale: The correct answer is C) Human placental lactogen (hPL). Explanation: Human placental lactogen (hPL) is a hormone produced by the placenta during pregnancy. It plays a role in promoting insulin resistance in the mother, which helps ensure a steady supply of glucose to the fetus. After delivery, hPL levels drop rapidly. This decrease in hPL leads to decreased insulin resistance, allowing glucose levels to normalize. A) Estrogen and B) Progesterone do not directly impact glucose levels in the same way as hPL. Estrogen and progesterone levels also drop postpartum but do not have a significant effect on glucose regulation. D) Human chorionic gonadotropin (hCG) is a hormone produced during pregnancy that is responsible for maintaining the corpus luteum, which in turn produces progesterone to support the pregnancy. However, hCG levels drop quickly after delivery and do not play a significant role in glucose regulation postpartum. Educational Context: Understanding the hormonal changes that occur postpartum is crucial for healthcare providers managing patients with diabetes, especially type 1 diabetes. Recognizing the impact of hPL on glucose levels can help healthcare professionals anticipate and manage blood glucose levels in the postpartum period, ensuring optimal care for both the mother and the newborn.

Correct Answer: C

Rationale: In this scenario, option C, "Encourage the couple to try to get pregnant again in the near future," is not an appropriate nursing action. It is crucial to provide sensitive and empathetic care to a couple who has experienced a fetal demise at 28 weeks. Encouraging them to try to get pregnant again in the near future can be emotionally insensitive and could potentially hinder their grieving process. Option A, "Swaddle the baby in a baby blanket," may provide the couple with the opportunity to hold and say goodbye to their baby, facilitating the grieving process. Option B, "Discuss funeral options for the baby," is important as it allows the couple to make decisions about honoring their baby's memory and provides closure. Option D, "Ask the couple whether they would like to hold the baby," is also appropriate as it gives the couple a chance to bond with their baby and create memories. In an educational context, it is vital for healthcare providers to be well-versed in providing compassionate care to individuals experiencing pregnancy loss. Understanding the emotional complexities involved and knowing how to support individuals through the grieving process is essential in delivering holistic care. By choosing appropriate actions and responses, healthcare providers can help facilitate healing and promote emotional well-being during such challenging times.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Postpartum hemorrhage. Postpartum hemorrhage is a major concern after delivery and is one of the leading causes of maternal mortality worldwide. It can occur due to various reasons, including uterine atony, retained placental tissue, or lacerations. The other options are incorrect because: A) Endometrial ischemia: While important, endometrial ischemia does not present an immediate threat post-delivery compared to postpartum hemorrhage. C) Prolapsed uterus: This is a rare complication that usually occurs later and is not typically associated with the immediate postpartum period. D) Vaginal hematoma: While vaginal hematomas can occur post-delivery, they are not as life-threatening as postpartum hemorrhage. Educational context: It is crucial for nurses and healthcare providers to be vigilant for signs and symptoms of postpartum hemorrhage in the immediate postpartum period. This includes monitoring vital signs, assessing uterine tone, and observing for excessive bleeding. Early recognition and prompt intervention are vital in managing postpartum hemorrhage effectively and preventing adverse outcomes for the mother.