93. A client, who is gravida 1, para 0, delivers an infant at 39 weeks' gestation. The client's blood type is O negative and the baby is O positive. A physician orders an injection of Rho(D) immune globulin. To provide adequate postpartum prophylaxis, when should a nurse administer Rho(D) immune globulin?
. Within 72 hours of delivery.
. Within 1 week of delivery.
. Before 12 hours after delivery.
. Within 2 weeks of delivery.
Test-Taking Tip
Since Rho(D) immune globulin is administered in the hospital, eliminate the time frames that would be longer than the average hospital stay for delivery. Is it hours or weeks? 72 hours is a reasonable length of time.
Content Area: Maternity, Postpartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Pharmacological and Parenteral Therapies/Medication Administration
.
Answer 1 is correct because Rho(D) immune globulin needs to be administered before 72 hours after delivery to be effective. Answer 2 is incorrect because 1 week is too long after delivery for adequate prophylaxis. Answer 3 is incorrect because Rho(D) immune globulin does not need to be administered by 12 hours of age. Adequate prophylaxis is obtained if administration is within 72 hours after delivery. Answer 4 is incorrect because 2 weeks is too long after delivery for adequate prophylaxis.