The graduate nurse (GN) receives report on a postpartum client with an Rh-negative blood type. Which statement by the GN regarding the Rh immune globulin injection requires the preceptor to provide further teaching?

Question

The graduate nurse (GN) receives report on a postpartum client with an Rh-negative blood type.  Which statement by the GN regarding the Rh immune globulin injection requires the preceptor to provide further teaching?

Quizplus · Accepted Answer

11ecbb05_cc2a_5736_b433_cddeeb7061b6_MD0009_00 Rh alloimmunization (ie, isoimmunization) occurs when a pregnant client with an Rh-negative blood type is exposed to Rh-positive fetal RBCs during pregnancy and birth. After exposure, the maternal immune system produces antibodies to the Rh antigen that can cause serious complications for an Rh-positive fetus during future pregnancies (eg, hemolytic anemia). Rh immune globulin (RhoGAM) prevents antibody formation by suppressing the maternal immune response and is effective only if the client has never developed antibodies to the Rh antigen (ie, Rh sensitization). The nurse should verify that the client is not Rh sensitized by checking for a negative antibody screen (eg, indirect Coombs test) and then proceeding with administration of Rh immune globulin (Option C). A positive maternal antibody screen would require further clarification from the health care provider (HCP). (Option A) If the HCP suspects excessive fetomaternal hemorrhage, a Kleihauer-Betke stain is performed to quantify the fetal RBCs in maternal circulation. Depending on the quantity of fetal RBCs, >1 dose of Rh immune globulin may be required. (Option B) Rh immune globulin should be administered within 72 hours of birth to ensure effectiveness. (Option D) If the newborn is Rh negative, Rh immune globulin is not necessary postpartum. Educational objective: Rh alloimmunization occurs when a pregnant client with an Rh-negative blood type is exposed to Rh-positive fetal RBCs. Postpartum, the nurse should verify that the client is not Rh sensitized by checking for a negative antibody screen and then proceeding with administration of Rh immune globulin if the newborn is Rh positive.

The Graduate Nurse (GN) Receives Report on a Postpartum Client