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?
Verify that the newborn is Rh-negative.
Verify that the client’s Coombs test is positive.
Administer the medication within 72 hours after birth.
Administer the medication into the client’s abdomen.
The Correct Answer is C
Choice A rationale
Verifying that the newborn is Rh-negative is not necessary for administering Rh(D) immune globulin. The medication is given to Rh-negative mothers to prevent Rh sensitization, regardless of the newborn’s Rh status.
Choice B rationale
A positive Coombs test indicates that the mother has already been sensitized to Rh-positive blood cells, making Rh(D) immune globulin ineffective in preventing sensitization.
Choice C rationale
Administering Rh(D) immune globulin within 72 hours after birth is crucial to prevent Rh sensitization in future pregnancies. This timing ensures that the mother’s immune system does not produce antibodies against Rh-positive blood cells.
Choice D rationale
Rh(D) immune globulin is typically administered intramuscularly, not into the abdomen. The preferred sites are the deltoid muscle or the anterolateral aspect of the thigh.
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Correct Answer is D
Explanation
Choice A rationale
Providing additional hydration by offering glucose water is not recommended. Breast milk or formula should be the primary source of hydration for newborns.
Choice B rationale
Monitoring the newborn’s heart rate every 2 hours is not necessary for phototherapy. The focus should be on monitoring bilirubin levels, hydration status, and ensuring the newborn’s eyes are protected.
Choice C rationale
Applying a water-based lotion to the newborn’s skin every 4 hours is not recommended. Lotions can interfere with the effectiveness of phototherapy and may cause skin irritation.
Choice D rationale
Removing the newborn from phototherapy every 2 hours for breastfeeding is recommended. Frequent breastfeeding helps to promote bilirubin excretion and maintain hydration.
Correct Answer is D
Explanation
Choice A rationale
A temperature of 37.8°C (100°F) 18 hours postpartum is slightly elevated but not necessarily indicative of a serious issue. It may require monitoring but is not the most urgent concern.
Choice B rationale
Abdominal pain during breastfeeding 8 hours postpartum is a common experience due to uterine contractions. While it may cause discomfort, it is not typically an urgent concern.
Choice C rationale
Not having a bowel movement 24 hours postpartum is not uncommon and does not usually require immediate attention. It can be addressed with dietary changes and other interventions.
Choice D rationale
Saturating one perineal pad over 2 hours 6 hours postpartum in a G5P4 client indicates a potential risk of postpartum hemorrhage. This is a more urgent concern that requires immediate assessment and intervention to prevent complications.