A nurse is caring for a client who is postpartum and has a prescription for Rho (D) Immunoglobulin. The nurse should verify which of the following prior to administration?

A) Fundal height below the umbilicus:

In the immediate postpartum period, the fundus typically descends at a predictable rate. A fundal height below the umbilicus on the first day postpartum is expected. It is not a cause for immediate intervention unless accompanied by other signs of postpartum hemorrhage.

B) Decreased urge to void:

A decreased urge to void is common in the immediate postpartum period due to perineal swelling, episiotomy or lacerations, and the effects of regional anesthesia. However, it is not an immediate concern as long as the client is voiding adequate amounts of urine.

C) Increased urine output:

Increased urine output in the postpartum period is expected due to the diuretic effect of the body eliminating excess fluid retained during pregnancy. It is not a cause for immediate intervention as long as the client is not exhibiting signs of dehydration.

D) Displaced fundus from the midline:

A displaced fundus from the midline is concerning as it may indicate uterine atony, which is the most common cause of postpartum hemorrhage. Immediate intervention is necessary to prevent further complications such as excessive bleeding.

A) Dry the infant off and cover the head:

While drying the infant and covering the head are important steps in newborn care to prevent heat loss and maintain thermal regulation, clearing the respiratory tract takes precedence immediately after delivery to ensure adequate breathing and oxygenation.

B) Stimulate the infant to cry:

While it is essential for newborns to establish effective respiratory efforts, stimulating the infant to cry is not the first action indicated after delivery. Crying may naturally occur as a response to the new environment, but it is not a reliable indicator of effective respiratory function.

C) Cut the umbilical cord:

Cutting the umbilical cord is typically done after the initial steps of newborn care, including clearing the respiratory tract. It is important to ensure that the infant is breathing adequately before attending to other tasks such as cord cutting.

D) Clear the respiratory tract:

Clearing the newborn's respiratory tract is the priority action immediately after delivery to ensure that the airway is clear of any amniotic fluid or debris, facilitating effective breathing and oxygenation. This may involve suctioning the mouth and nose as needed to remove any secretions and ensure unobstructed airflow.