A nurse is caring for a client, PP2, who is preparing to go home with her infant. The nurse notes that the client's blood type is O− (negative), the baby's type is A+ (positive), and the direct Coombs' test is negative. Which of the following actions by the nurse is appropriate?

Correct Answer: B

Rationale: The correct answer is B: Make sure that the client receives a RhoGAM injection before she is discharged from the hospital. In the context of postpartum care, when a mother is Rh-negative and the baby is Rh-positive, there is a risk of Rh incompatibility. If fetal blood enters the maternal circulation during childbirth, the mother's immune system can mount an immune response against the Rh-positive blood cells, leading to potential issues in subsequent pregnancies. RhoGAM is administered to Rh-negative mothers to prevent this immune response. It works by binding to any fetal Rh-positive cells in the mother's bloodstream, preventing her immune system from reacting to them. Administering RhoGAM within 72 hours postpartum is crucial to prevent sensitization in future pregnancies. The other options are incorrect because: A) Waiting until the end of the week for the RhoGAM injection is too late to be effective. C) The baby's negative Coombs' test does not negate the need for the mother to receive RhoGAM. D) Discharge timing should not delay the administration of RhoGAM, as it is time-sensitive. Understanding the rationale behind the administration of RhoGAM in Rh-negative mothers is essential for nurses to provide safe and effective care to postpartum clients and their infants. It highlights the importance of timely interventions to prevent complications in future pregnancies due to Rh incompatibility.

Correct Answer: A

Rationale: In this scenario, the nurse should report the magnesium level of 7 mg/dL to the surgeon. Postpartum eclampsia is a condition characterized by seizures and is treated with magnesium sulfate to prevent further seizures. Monitoring magnesium levels is crucial due to its narrow therapeutic range, and levels above 7-8 mg/dL can lead to magnesium toxicity, causing respiratory depression and cardiac arrest. The other options are incorrect because: - Option B, Sodium 136 mg/dL, is within the normal range. - Option C, Potassium 3.0 mg/dL, is slightly low but not critical in this context. - Option D, Calcium 9 mg/dL, is also within the normal range. Educationally, this case highlights the importance of monitoring electrolyte levels, especially magnesium, in postpartum eclampsia patients receiving magnesium sulfate therapy. Nurses should understand the significance of each electrolyte in relation to the patient's condition and treatment to provide safe and effective care. Regular monitoring and prompt reporting of abnormal values are essential in preventing complications and ensuring optimal patient outcomes.

Correct Answer: B

Rationale: In the postpartum period, especially in the presence of deep vein thrombosis (DVT), the client is at high risk for a stroke. This is because DVT can lead to the formation of blood clots that can travel to the brain, causing a stroke. Option A, hemorrhage, is less likely as DVT is associated with clot formation rather than excessive bleeding. Option C, endometritis, is more commonly associated with postpartum infections rather than DVT. Option D, hematoma, is a localized collection of blood outside of blood vessels and is not directly related to the complications of DVT. Educationally, understanding these postpartum hormonal changes and associated risks is crucial for healthcare providers to provide appropriate care and interventions to prevent serious complications like stroke in postpartum clients with DVT. It highlights the importance of thorough assessment, monitoring, and early intervention in managing postpartum complications.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Benadryl (diphenhydramine). The client's symptoms of pruritus and macular rash are indicative of an allergic reaction, which is a common side effect of spinal anesthesia. Benadryl is an antihistamine that can help alleviate these symptoms by blocking the histamine response responsible for the itching and rash. Option A) Reglan (metoclopramide) is used to treat nausea and vomiting, which are not the primary symptoms presented by the client. Option B) Zofran (ondansetron) is also used for nausea and vomiting, not pruritus or rash. Option C) Compazine (prochlorperazine) is an antiemetic used for nausea and vomiting, not allergic reactions like pruritus and rash. In an educational context, understanding the side effects and appropriate interventions for common medications used in the postpartum period is crucial for nurses caring for maternal clients. Recognizing and managing allergic reactions promptly is essential to ensure the well-being and comfort of the client. Diphenhydramine is a commonly used antihistamine in such situations, making it a valuable medication to have knowledge about in the postpartum setting.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Mastitis. Mastitis is an infection of the breast tissue that can occur due to various factors, including retained placental fragments. In this case, the retained placental fragments can lead to an infection, causing inflammation and pain in the affected breast. Common symptoms of mastitis include redness, warmth, swelling, and tenderness in the breast, accompanied by flu-like symptoms such as fever and body aches. Option A) Engorgement is incorrect because engorgement typically occurs when the breasts become overly full with milk, leading to swelling and discomfort, but it is not directly related to retained placental fragments causing an infection. Option C) Blocked milk duct is incorrect as it occurs when milk is unable to flow freely within the duct, often due to pressure on the duct, but it is not specifically associated with an infection caused by retained placental fragments. Option D) Low milk supply is incorrect in this context because retained placental fragments leading to mastitis would not directly impact milk production. Low milk supply can be influenced by various factors such as inadequate breastfeeding or hormonal issues, but it is not the expected complication in this scenario. Educationally, understanding the potential complications of retained placental fragments in breastfeeding women is crucial for nurses and healthcare providers to provide appropriate care and support. Recognizing the signs and symptoms of mastitis, differentiating it from other breastfeeding issues, and initiating prompt treatment are essential in ensuring the well-being of both the mother and the infant. This knowledge helps in promoting successful breastfeeding outcomes and maternal health postpartum.