A nurse is assisting with the care of a client who is in labor and has the urge to push.
Which of the following instructions should the nurse give the client?

Choice A rationale:

Rh positive individuals already have the Rh factor on their red blood cells, so they do not need Rho(D) immune globulin to

prevent sensitization.

The newborn being Rh positive does not pose a risk to an Rh positive mother, as their blood types are compatible.

Choice B rationale:

Rh positive individuals cannot develop antibodies against the Rh factor, as it is already present on their own red blood cells.

The newborn's Rh negative status does not create a risk of sensitization for the mother, as there is no Rh factor to trigger an

immune response.

Choice C rationale:

If both the mother and the newborn are Rh negative, there is no risk of Rh incompatibility.

This is because neither individual has the Rh factor on their red blood cells, so there is no potential for sensitization.

Choice D rationale:

When an Rh negative mother carries an Rh positive fetus, there is a risk of Rh sensitization during pregnancy and delivery.

This occurs when fetal blood cells cross the placenta and enter the mother's bloodstream, exposing her immune system to the

Rh factor.

If the mother's immune system recognizes the Rh factor as foreign, it can produce antibodies against it.

These antibodies can cross the placenta in subsequent pregnancies and attack the red blood cells of Rh positive fetuses,

leading to hemolytic disease of the newborn (HDN).

Rho(D) immune globulin is a medication that can prevent Rh sensitization by binding to Rh positive fetal blood cells that have

entered the mother's bloodstream.

This prevents the mother's immune system from recognizing the Rh factor and producing antibodies.

Rho(D) immune globulin is typically given to Rh negative mothers within 72 hours of delivery of an Rh positive newborn, as well as after other events that could lead to Rh sensitization, such as miscarriage, abortion, or ectopic pregnancy.

Choice A rationale:

The fundus at the umbilicus level is a normal finding in the immediate postpartum period. After delivery, the top of the uterus

(known as the fundus) is typically at the level of the umbilicus. In the days following delivery, the uterus begins to shrink and

descend into the pelvic cavity, guided by the process known as involution.

Choice B rationale:

A urinary output of 3,000 mL is unusually high and could indicate a postpartum complication. Postpartum diuresis is common

as the body eliminates excess fluid accumulated during pregnancy. However, excessive urinary output could be a sign of

postpartum complications such as postpartum preeclampsia, which can occur after the birth of the baby and is characterized

by high blood pressure and signs of damage to another organ system, often the kidneys.

Choice C rationale:

A temperature of 100.4 F for two days postpartum can be a normal finding. It’s not uncommon for women to experience a

slight elevation in temperature in the first 24 hours after delivery due to the exertion of labor. However, a temperature above100.4 F beyond the first 24 hours could indicate an infection and should be evaluated.

Choice D rationale:
A cesarean section shortly following delivery is not typically a sign of a postpartum complication. It’s a surgical procedure used to deliver the baby and can be planned or unplanned due to various reasons such as the baby’s position, multiple pregnancies, or complications during labor. However, like any surgery, a cesarean section does carry risks and can increase the likelihood of certain postpartum complications such as infection or blood clots.