Question

The nurse is preparing a woman for discharge after a birth and notes the mother's record indicates rh negative and rubella titer is positive. which nursing intervention will the nurse prioritize?

Answer 1

The answer is to assess the Rh or as called as rhesus of the baby. In addition, the cord blood should be evaluated to determine the Rh type of the infant. If it is negative, there is no need for any further action or concern. However, if it is Rh positive the mother needs to be evaluated for possible supervision of RhoGAM.

The measures for giving RhoGAM are as follows:

• The woman must be Rho (D) negative.

• The woman must not have anti-D antibodies which are must not be sensitized.

• The infant should be Rho (D) positive in which the fetus cord blood is checked after birth.

• A direct Coombs test which is a test for antibodies performed on cord blood at delivery and must be weakly reactive or negative.


All of these requirements to be accomplished in the first 72 hours of birth, so the mother can obtain RhoGAM in the appropriate time frame.