A nurse is caring for a 24-year-old female client in the postpartum unit. The client has a history of type 1 diabetes mellitus, first diagnosed at 14 years of age, and is on insulin for diabetes management. The client is gravida 1 para 1 following a spontaneous vaginal birth at 37 weeks of gestation. The newborn was large for gestational age, weighing 4.1 kg (9 lb). The client has a third-degree laceration that required several stitches.

Exhibits

Drag words from the choices below to fill in each blank in the following sentence.

Sentence: The nurse should plan to

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and

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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.

Choice A rationale

Applying lotion to the newborn’s extremities every 8 hours is not recommended during phototherapy. Lotions and ointments can cause burns when exposed to phototherapy lights and may interfere with the treatment’s effectiveness.

Choice B rationale

Repositioning the newborn every 4 hours is not frequent enough. The newborn should be repositioned every 2 hours to ensure even exposure to the phototherapy light and to prevent pressure sores.

Choice C rationale

Removing the eye mask during feedings is correct. The eye mask should be removed during feedings to allow for bonding and to check for any signs of irritation or infection. This also ensures that the newborn’s eyes are protected from the phototherapy light when not under the lamp.

Choice D rationale

Supplementing feedings with glucose water is not recommended. Breast milk or formula should be used to ensure the newborn receives adequate nutrition and hydration. Glucose water does not provide the necessary nutrients and can interfere with breastfeeding.