The nurse receives the following report on a patient who delivered 36 hours ago: para 1, rubella-immune, A-negative, antibody screen negative, newborn B-positive, Coombs' negative, discharge orders are written for both mother and newborn
What should be the priority action by the nurse? 1. Ask whether the mother is breast- or bottle-feeding.
2. Administer rubella vaccine.
3. Determine whether RhoGAM has been given.
4. Discuss the discharge education with the patient.
3
Rationale 1: This is important but is not the top priority.
Rationale 2: The client is rubella-immune, and does not need the rubella vaccine.
Rationale 3: The patient is A-negative and the newborn B-positive. The patient needs RhoGAM prior to discharge. Without RhoGAM, the patient will make antibodies against Rh-positive blood, and future pregnancies would be in jeopardy.
Rationale 4: Discharge education is always important, but in this case is not the most important action.
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