A nurse is caring for a client who delivered a healthy newborn 2 hours ago. The client's blood type is O negative, and the newborn's blood type is A positive.
Which nursing action is most appropriate?
Withhold Rho(D) immune globulin (Rhogam) because the mother has already delivered.
Administer Rhogam within 72 hours postpartum.
Withhold Rhogam because there is no indication for a second dose with the newborn's blood type.
Administer Rhogam only if the mother plans future pregnancies.
The Correct Answer is B
Choice A rationale
Rho(D) immune globulin, or Rhogam, is crucial for preventing Rh sensitization in an Rh-negative mother carrying an Rh-positive fetus. Sensitization can occur during delivery when fetal Rh-positive red blood cells enter the maternal circulation. Rhogam must be administered postpartum to destroy these fetal cells before the mother's immune system can produce permanent anti-D antibodies, regardless of the timing of the delivery.
Choice B rationale
The Rh-negative mother is at risk of isoimmunization when her newborn is Rh-positive, as is the case here. Rho(D) immune globulin works by suppressing the mother's antibody response to the Rh-positive fetal red blood cells. To be effective, this passive immunity must be provided by administering the medication, typically a full 300 mcg dose, within 72 hours of birth to prevent permanent sensitization.
Choice C rationale
The newborn's A-positive blood type means the infant possesses the Rh (or D) antigen, which is the indication for Rhogam administration to the Rh-negative mother. There is no mention of a prior dose or second dose; this would be the necessary first postpartum dose. The presence of the Rh antigen in the newborn makes this a required intervention to protect future pregnancies.
Choice D rationale
Rho(D) immune globulin must be administered within 72 hours postpartum irrespective of the mother's plans for future pregnancies. Once sensitization occurs, it is permanent and will put all subsequent Rh-positive fetuses at risk for severe hemolytic disease of the newborn. Protecting the current and future fetuses is the clinical imperative, making the dose mandatory. —.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Uterine atony, the lack of uterine muscle tone, is the most common cause of immediate postpartum hemorrhage (PPH). The boggy (soft, not firm) and displaced fundus (to the right) strongly suggest the uterus is not contracting effectively, which allows blood vessels at the placental site to bleed freely. Furthermore, a distended bladder due to incomplete or infrequent voiding (last void 4 hours ago) can physically displace the uterus, impairing its ability to contract and leading to atony, heavy bleeding, and clot formation.
Choice B rationale
While a bleeding disorder can cause PPH, it is less likely to be the primary cause when classic signs of uterine atony are present. A bleeding disorder would typically be associated with generalized bleeding from all sites and possibly abnormal coagulation lab values (e.g., prolonged PT/INR, PTT, low platelet count-normal: 150,000-450,000/μ L). The physical assessment findings of a boggy, displaced fundus are more indicative of a mechanical issue with uterine contraction.
Choice C rationale
A 4th-degree laceration extends through the anal sphincter and rectal mucosa, causing pain and a risk for infection or dehiscence. While it contributes to overall blood loss, it typically causes steady, bright red bleeding despite a firm fundus. The fundal displacement and boggy consistency with large clots are the hallmark signs pointing away from the laceration as the primary source of the current heavy bleeding.
Choice D rationale
A hematoma is a collection of blood in the connective tissue, often in the vagina or perineum, characterized by severe pain, pressure, and possibly a tense, firm, bulging mass. While the patient is sore, the main concern here is the heavy vaginal bleeding accompanied by the boggy and displaced fundus. A hematoma generally does not cause the profuse, clot-filled bleeding that results from uterine atony. —.
Correct Answer is {"A":{"answers":"G,D,I"},"B":{"answers":"C,E,F"},"C":{"answers":"A,B,H"}}
Explanation
The correct answer is:. Rubra: Lasts from day 1-3 postpartum, Dark red color, Fleshy odor. Serosa: Serosanguineous consistency, Pinkish/brown color, Lasts from day 4-10 postpartum. Alba: Consists of mucus and leukocytes, Yellowish/white color, Lasts from day 10-8 weeks postpartum. .
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