A 22-year-old female client, 41 weeks' gestation G1P0, with a history of asthma and anxiety, is brought to the hospital reporting contractions increasing in quality and frequency for 4 hours and her water broke 30 minutes prior to arrival.
Upon admission, what is the priority nursing action?

Choice A rationale

Placing a rolled towel under the client's knees is generally discouraged because it can promote venous stasis in the lower extremities by compressing the popliteal vein, thereby increasing the risk of developing a deep vein thrombosis (DVT). While comfort measures are important, this specific action is not a critical immediate action necessary for safety or to advance care upon admission to the labor unit.

Choice B rationale

The healthcare provider must be notified of the client's admission and status, but this is not the most critical immediate action for the nurse. The immediate priority upon admission is to complete the initial assessment, which includes establishing the fetal heart rate (FHR) baseline (which is currently being monitored) and assessing the stage of labor through a sterile vaginal exam, then notifying the provider with complete findings.

Choice C rationale

Administering supplemental oxygen via a non-rebreather mask (NRB) is indicated for signs of maternal hypoxemia (low oxygen saturation) or for fetal distress. Although the client has an increased respiratory and cardiac rate, her lungs are clear, and she is alert, suggesting anxiety or labor pain is the likely cause. Oxygen is not immediately required without evidence of true hypoxemia.

Choice D rationale

Performing a sterile vaginal exam (SVE) to assess cervical dilation and effacement is a critical, immediate action upon admission to the labor unit to determine the stage of labor. This information is essential for triage, ongoing management, and planning. It provides the baseline data needed to compare against subsequent exams and to communicate the client's status effectively to the healthcare provider.

Choice A rationale

Rho(D) immune globulin, or RhoGAM, is an exogenous preparation of anti-D antibodies that bind to any fetal Rh-positive red blood cells that enter the maternal circulation, effectively clearing them before the mother's immune system recognizes the D antigen and mounts an immune response. This prevents sensitization, allowing the woman to have unlimited subsequent Rh-positive children without the risk of developing hemolytic disease of the fetus and newborn (HDFN).

Choice B rationale

The recommendation is not limited to only two children if Rho(D) immune globulin is administered correctly. The medication provides passive immunity to prevent the mother from producing her own anti-D antibodies, which are the cause of HDFN in subsequent Rh-positive fetuses. Administration within 72 hours postpartum and often prophylactically around 28 weeks gestation is standard practice.

Choice C rationale

If Rh sensitization has occurred in a prior pregnancy or due to other exposure and Rho(D) immune globulin was not given, the mother's immune system will have produced anti-D antibodies. These immunoglobulin G (IgG) antibodies can cross the placenta and affect all subsequent Rh-positive fetuses, not just the next one, potentially causing fetal hemolysis and severe anemia.

Choice D rationale

Hemolytic disease of the fetus and newborn (HDFN) is determined by the fetal Rh status, specifically the presence of the D antigen on the fetal red blood cells, which is an autosomal dominant trait. The sex of the fetus (male or female) is genetically unrelated to the inheritance of the Rh factor and does not influence the severity or occurrence of the Rh incompatibility reaction.