A woman with a history of heart failure is in labor and has the ...

[pane00]

A woman with a history of heart failure is in labor and has the following vital signs: blood pressure: 100/58 mm Hg, pulse: 120 beats/minute, respiratory rate: 36 breaths/minute, oxygen saturation: 88. Which action should the nurse perform first?
 
  A.
  Administer oxygen at 10 L/min per rebreather mask.
  B.
  Call the health-care provider to report the results.
  C.
  Document the findings in the patient's chart.
  D.
  Increase the woman's IV infusion to 150 mL/hour.

Question 2

A nurse is preparing to dismiss a woman and her infant from the hospital. The woman is Rh(D)-negative and the infant is Rh(D)-positive. This was her first pregnancy. Which nursing action is most appropriate?
 
  A.
  Administer Rho(D) immune globulin (RhoGAM) and document accurately.
  B.
  Assess the father to see if he has ever received an injection of RhoGAM.
  C.
  Educate the woman on the need for RhoGAM if she delivers an Rh(D)-negative baby.
  D.
  Instruct the woman to get RhoGAM with her next pregnancy, not for this one.

[dmurph1496]

Answer to Question 1

ANS: A
The patient is exhibiting signs of decreased cardiac output and her low SaO2 indicates that she needs oxygen, which should be supplied at 10 L/min per rebreather mask. Calling the provider and documentation are important actions but do not take priority over promptly treating the woman. She does not need increased IV fluids, and, in fact, increasing the IV fluid rate will likely worsen her condition.

Answer to Question 2

ANS: A
Administering RhoGAM correctly and documenting it is a critical nursing action when indicated. An unsensitized Rh(D)-negative woman should be given RhoGAM within 72 hours of delivery of an Rh(D)-positive baby. RhoGAM is not administered to the father or to the baby. If an Rh(D)-negative woman gives birth to an Rh(D)-negative baby, she does not need RhoGAM. The woman should be tested for sensitivity during her next, and all subsequent, pregnancies.