A nurse is preparing to dismiss a woman and her infant from the hospital. The woman is Rh(D)-negative and the infant is Rh(D)-positive. This was her first pregnancy. Which nursing action is most appropriate?
A.
Administer Rho(D) immune globulin (RhoGAM) and document accurately.
B.
Assess the father to see if he has ever received an injection of RhoGAM.
C.
Educate the woman on the need for RhoGAM if she delivers an Rh(D)-negative baby.
D.
Instruct the woman to get RhoGAM with her next pregnancy, not for this one.
ANS: A
Administering RhoGAM correctly and documenting it is a critical nursing action when indicated. An unsensitized Rh(D)-negative woman should be given RhoGAM within 72 hours of delivery of an Rh(D)-positive baby. RhoGAM is not administered to the father or to the baby. If an Rh(D)-negative woman gives birth to an Rh(D)-negative baby, she does not need RhoGAM. The woman should be tested for sensitivity during her next, and all subsequent, pregnancies.
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