RN Nursing · Newborn Care and Parent Teaching · Practice question
A postpartum nurse is reviewing the lab results of a client who is Rh-negative and recently delivered an Rh-positive newborn. The Kleihauer-Betke test indicates fetal blood cells in the maternal circulation. Which action should the nurse prioritize?
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Monitor the client for signs of infection and prepare to start antibiotics immediately.
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✓
Administer Rho(D) immune globulin to the client to prevent Rh sensitization.
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Schedule a blood transfusion for the client to manage potential anemia.
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Encourage early breastfeeding to enhance maternal-infant bonding and immune protection.
Answer & explanation
Correct: Administer Rho(D) immune globulin to the client to prevent Rh sensitization.
When an Rh-negative mother delivers an Rh-positive infant and the Kleihauer-Betke (KB) test confirms fetal-to-maternal hemorrhage, the priority intervention is administration of Rho(D) immune globulin (RhoGAM). The KB test quantifies the volume of fetal red blood cells that have entered maternal circulation; this information is used to calculate the appropriate dose of Rho(D) immune globulin needed to neutralize the Rh-positive fetal cells before the mother's immune system can produce anti-D antibodies. If sensitization occurs, subsequent Rh-positive pregnancies carry risk of hemolytic disease of the fetus and newborn. Rho(D) immune globulin must be given within 72 hours of delivery to be effective, making this a time-sensitive nursing priority. Monitoring for infection and starting antibiotics addresses a completely different clinical problem and is not indicated by these findings. A blood transfusion is only appropriate if the mother demonstrates significant anemia, which is not indicated solely by a positive KB test. Encouraging breastfeeding supports bonding and infant immune benefits but has no relevance to preventing Rh sensitization. The nurse should confirm the dose required based on the KB test result — a standard 300-mcg dose covers approximately 30 mL of fetal whole blood — and administer it promptly.
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