Home » NCLEX » NCLEX-PN » Which of the following nursing actions should be included in the client’s care plan?
An Rh-negative woman with previous sensitization has delivered an Rh-positive fetus. Which of the following nursing actions should be included in the client’s care plan?
A. emotional support to help the family deal with feelings of guilt about the infant’s condition
B. administration of MICRhoGam to the woman within 72 hours of delivery
C. administration of Rh-immune globulin to the newborn within 1 hour of delivery
D. lab analysis of maternal Direct Coombs’ test
Correct Answer: A
Explanation/Reference:
Explanation:
If a woman is sensitized to the Rh factor, it poses a threat to any Rh-positive fetus she delivers. The nurse needs to provide emotional support to help the family deal with the infant’s condition, which might involve a host of conditions that could lead to death or marked neurological damage. RhoGam is never given to a woman already sensitized. If not previously sensitized, MICRhoGam (a smaller dose of Rh immune globulin) is given after an abortion or ectopic pregnancy to prevent sensitization. If not sensitized, RhoGam is given to the woman within 72 hours of delivery. Rh-immune globulin is never given to the newborn. To determine if sensitization has occurred, an Indirect Coombs’ is drawn on the mother to measure the number of Rh-positive antibodies.Health Promotion and Maintenance
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