A nurse is caring for a client who is postpartum.



Which of the following findings is an indication for the nurse to administer Rho(D) immune globulin?

Choice A rationale:

Significance of retraction: Retraction of the fetal head against the maternal perineum is a crucial sign that the fetal shoulders

are about to be delivered. It indicates that the fetal head has fully descended into the pelvic outlet and is ready to rotate and

deliver the shoulders.

Urgency of preparation: It's essential for the nurse to promptly prepare for the delivery of the shoulders to ensure a safe and

timely birth:

Gather necessary equipment, including sterile gloves, towels, and possibly a suction bulb.

Position the mother appropriately, often in a semi-sitting or lithotomy position, to facilitate delivery.

Support the perineum to reduce tearing and guide the delivery of the shoulders.

Communicate with the mother to encourage effective pushing and maintain clear instructions throughout the process.

Anticipate potential complications, such as shoulder dystocia, and be prepared to assist with maneuvers to resolve it if

necessary.

Choice B rationale:

Rest during second stage: While rest is important during labor, encouraging rest between contractions at this specific point

(retraction of the head) could delay the delivery of the shoulders, potentially increasing risks for both mother and baby.

Maintaining momentum: The second stage of labor typically involves active pushing and uterine contractions to facilitate

delivery. Resting at this stage could interrupt the natural progression of labor.

Choice C rationale:

Role of blood pressure monitoring: Monitoring blood pressure is essential throughout labor to detect potential complications

like preeclampsia or hemorrhage. However, in this specific scenario, where the fetal head is already retracted and the

shoulders are imminent, preparing for delivery takes priority over routine blood pressure checks.

Choice D rationale:

Oxygen administration: Oxygen is sometimes administered during labor to support the mother's and baby's oxygen levels.

However, it's not a standard intervention for all laboring women, and its necessity would be based on individual assessments

and clinical judgment. In the absence of specific indications for oxygen, such as maternal distress or fetal heart rate concerns,

it's not the priority action when the fetal head is retracted and delivery of the shoulders is impending.

Choice A rationale:

Increasing fluid intake is not the priority action in this situation. While maintaining adequate hydration is important for

postpartum recovery, it does not directly address the immediate concern of excessive bleeding. Excessive fluid intake could

potentially worsen the bleeding by increasing blood volume and potentially increasing blood pressure.

Choice C rationale:

Helping the client use the bedpan to urinate is not the priority action in this case. While a full bladder can sometimes interfere

with uterine contraction and contribute to postpartum bleeding, it is not the most likely cause of the excessive bleeding in this

scenario. The client has already saturated two perineal pads in a short period, indicating a more significant bleeding issue that

needs to be addressed first.

Choice D rationale:

Preparing to administer tocolytic medication is not the appropriate action at this time. Tocolytic medications are used to stop

contractions, but they are not typically used to manage postpartum hemorrhage. In fact, tocolytics could potentially worsen

the bleeding by interfering with the natural mechanisms that help the uterus contract and stop bleeding after delivery.

Choice B rationale:

Checking the consistency of the client's uterine fundus is the priority action in this situation. The most common cause of

postpartum hemorrhage is uterine atony, which means the uterus is not contracting effectively to clamp down on the blood

vessels where the placenta was attached. A soft, boggy fundus is a sign of uterine atony. By assessing the fundus, the nurse can

quickly determine if uterine atony is the likely cause of the bleeding and take appropriate interventions to manage it.