A nurse is caring for a client at 28 weeks gestation. The results of the laboratory examinations reveal that both the woman and the baby’s father are negative for Rh factor. An indirect Coombs test is negative. The nurse should expect which of the following actions?
  1. Document the findings; RhoGAM is not administered
  2. Assessment of maternal serum for alpha-fetoprotein
  3. Amniocentesis fluid is aspirated
  4. Administration of Rho immune globulin (RhoGAM)
Explanation
Answer - A - RhoGAM is administered at 26 to 28 weeks to an unsensitized Rh-negative mother. RhoGAM is also given within 72 hours after delivery, as the antibodies begin to form immediately after birth. If an Rh-positive child is born to an Rh-negative mother, the RhoGAM must be given in a timely manner. If not, the mother’s body will make antibodies against subsequent Rh-positive fetuses, causing anemia, brain damage and death.
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