A nurse is caring for a client who is Rh negative.
Which of the following findings would cause the nurse to administer Rh immunoglobulin?

Condition: Neonatal Jaundice.

2 actions:

Initiate phototherapy,

Encourage frequent breastfeeding or formula feeding.

2 parameters:

Serum bilirubin levels,

Blood glucose levels.

Rationale for correct condition: Neonatal jaundice is indicated by the elevated bilirubin levels and yellow discoloration of the skin and sclera. The newborn's symptoms of lethargy, decreased muscle tone, and poor feeding are consistent with jaundice. Jaundice is common in newborns and requires prompt treatment to prevent complications like kernicterus. The total bilirubin level of 15 mg/dL is significantly elevated and needs intervention.

Rationale for actions: Initiating phototherapy helps lower bilirubin levels by breaking down bilirubin in the skin. This treatment is effective and commonly used for neonatal jaundice. Encouraging frequent breastfeeding or formula feeding promotes regular bowel movements, which help eliminate bilirubin from the body. Adequate feeding is essential to reduce jaundice severity. Administering intravenous dextrose addresses hypoglycemia but does not directly treat jaundice. Performing a lumbar puncture is unnecessary unless sepsis is suspected. Naloxone is used for opioid withdrawal, not jaundice.

Rationale for parameters: Monitoring serum bilirubin levels tracks the effectiveness of phototherapy. This parameter is crucial for assessing jaundice severity and treatment response. Blood glucose levels should be monitored due to the initial low reading, ensuring the newborn's glucose levels stabilize. Respiratory rate is normal and not directly related to jaundice. Urine output monitors hydration but is less specific to jaundice. Heart rate is stable and not a primary focus.

Rationale for incorrect conditions: Neonatal hypoglycemia focuses on low blood glucose but doesn't explain jaundice. Neonatal sepsis presents with more systemic signs like fever or abnormal reflexes. Neonatal abstinence syndrome involves withdrawal symptoms from maternal substance use, not relevant here.

Choice A rationale

A red, tender area on the breast could indicate mastitis, an infection of the breast tissue. This requires prompt medical attention to prevent complications and provide appropriate treatment, often involving antibiotics.

Choice B rationale

A temperature of 100.8°F is considered a fever and could indicate an infection. Postpartum clients are at risk of infections, including endometritis, and should report any fever to their healthcare provider for further evaluation.

Choice C rationale

Burning on urination could indicate a urinary tract infection (UTI). UTIs are common postpartum due to catheter use and trauma during delivery. This symptom should be reported for evaluation and treatment if necessary.

Choice D rationale

Increased lochia rubra can indicate postpartum hemorrhage or retained placental fragments. Any significant change in bleeding pattern should be reported to ensure timely management and prevent serious complications.