A nurse is caring for a client in labor who is experiencing abruptio placentae. What findings should the nurse expect?

Choice A rationale

A Coombs positive result does not necessarily mean that the newborn will require immediate intervention. It indicates that the newborn should be monitored for potential complications such as jaundice and anemia.
Choice B rationale
While the newborn’s glucose level is within the normal range, this does not directly relate to the Coombs positive result.
Choice C rationale
A Coombs positive result may indicate Rh or ABO incompatibility, but this does not directly answer the question of what the nurse should anticipate.
Choice D rationale
This is the correct answer. A Coombs positive result indicates that the newborn should be monitored for signs of jaundice, as this could be a potential complication.

Choice A rationale
The report of perineal pain as 0 on a scale of 0 to 10 is not directly related to the effectiveness of the IV bolus of lactated Ringer’s. Perineal pain is more associated with the birthing process and not with the administration of IV fluids.
Choice B rationale
Relief of pruritus is not a direct indication of the effectiveness of the IV bolus of lactated Ringer’s. Pruritus, or itching, can be a side effect of certain medications or a symptom of various conditions, but it is not typically associated with the administration of IV fluids.
Choice C rationale

While increased urinary output can be a sign of adequate hydration, it is not the primary indicator of the effectiveness of a bolus of lactated Ringer’s. Urinary output can be influenced by various factors, including kidney function and fluid intake, but a single instance of increased urinary output does not necessarily indicate that the IV bolus was effective.
Choice D rationale
The primary goal of administering a bolus of IV fluids like lactated Ringer’s in a client who is in labor and has a prescription for spinal anesthesia is to maintain or improve the client’s hemodynamic status, which includes maintaining a stable blood pressure. Therefore, a blood pressure reading of 110/70 mm Hg indicates that the IV bolus was effective.