A nurse is assisting with the care of a client who is postpartum.

Exhibits

The nurse is collecting data from the client 24 hr later. How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or an indication that the client's condition is worsening.

A. Administer the medication into the client's abdomen. Rho(D) immune globulin (RhoGAM) is administered intramuscularly, typically in the deltoid or ventrogluteal muscle. It is not injected into the abdomen, as this is not a recommended route and may not ensure proper absorption of the medication.
B. Administer the medication within 72 h after birth. Rho(D) immune globulin should be given within 72 hours after delivery to prevent Rh isoimmunization in an Rh-negative mother with an Rh-positive newborn. This helps prevent the mother’s immune system from producing antibodies that could harm future pregnancies.
C. Verify that the newborn is Rh-negative. Rho(D) immune globulin is only necessary when the newborn is Rh-positive. If the newborn is Rh-negative, the mother does not require the injection, as there is no risk of Rh sensitization. The nurse should confirm the newborn's Rh status before administering the medication.
D. Verify that the client's Coombs test is positive. A positive Coombs test indicates that the mother has already developed antibodies against Rh-positive blood, meaning Rho(D) immune globulin would not be effective. The medication is only given if the Coombs test is negative, as it works to prevent sensitization rather than reverse it.

A. "I might develop a line down the middle of my stomach during pregnancy." The client is describing linea nigra, a common skin change in pregnancy caused by hormonal changes that increase melanin production. This dark line extends from the pubic area to the umbilicus (or higher) and usually fades after delivery.
B. "I can expect a yellow discharge from my vagina during the second trimester." A yellow vaginal discharge may indicate infection, such as bacterial vaginosis or sexually transmitted infections, which require medical evaluation. Normal vaginal discharge during pregnancy is known as leukorrhea, a thin, white, or milky discharge that increases due to hormonal changes.
C. "I might develop stretch marks on my stomach that will disappear after delivery." Stretch marks (striae gravidarum) commonly develop on the abdomen, breasts, and thighs due to skin stretching and hormonal influences. While they may fade over time, they do not completely disappear after delivery.
D. "I can expect to have Braxton Hicks contractions during the first trimester." Braxton Hicks contractions, or "false labor" contractions, typically begin in the second or third trimester as the uterus prepares for labor. They are usually irregular, painless, and do not indicate true labor. It is uncommon to experience Braxton Hicks contractions in the first trimester.