A nurse is caring for a client who is 6 hours postpartum. The client is Rh-negative and her newborn is Rh-positive. The client asks why an indirect Coombs test was ordered by the provider. Which of the following is an appropriate response by the nurse?
"It detects positive antibodies in the mother's blood."
"It detects Rh-negative antibodies in the newborn's blood."
"It determines if kernicterus will occur in the newborn."
"It determines the presence of maternal antibodies in the newborn's blood."
The Correct Answer is A
Choice A reason: The indirect Coombs test is used to screen for antibodies in the mother's blood that could potentially cause hemolytic disease in the newborn if they are Rh-positive. A positive result indicates that the mother has developed antibodies that could cross the placenta and attack the red blood cells of an Rh-positive fetus.
Choice B reason: The indirect Coombs test does not detect Rh-negative antibodies in the newborn's blood. Instead, it is used to detect antibodies in the mother's blood. The direct Coombs test is used to detect antibodies that are already attached to the red blood cells of the newborn.
Choice C reason: The indirect Coombs test does not determine if kernicterus will occur in the newborn. Kernicterus is a form of brain damage that can result from very high levels of bilirubin in a baby's blood. It is not directly related to the presence of antibodies detected by the indirect Coombs test.
Choice D reason: The indirect Coombs test does not determine the presence of maternal antibodies in the newborn's blood. This is assessed by the direct Coombs test, which checks for antibodies bound to the surface of the newborn's red blood cells, indicating that the immune system is attacking them.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Introducing fluoride supplements to a newborn is not typically recommended until the age of 6 months, unless advised by a healthcare provider due to specific water supply conditions. The American Academy of Pediatrics (AAP) suggests that fluoride supplementation should begin at 6 months if the water supply is deficient in fluoride.
Choice B reason:
Cow's milk is not recommended for infants under the age of 1 year. Introducing cow's milk before this age can lead to iron deficiency and potentially cause harm to the infant's developing kidneys. It also lacks the proper nutrients that infants require, which are found in breast milk or formula.
Choice C reason:
The AAP recommends that fruit juice should not be introduced to infants before 6 months of age. Before this age, babies should only be fed breast milk or formula. Introducing fruit juice too early can contribute to excessive weight gain and tooth decay.
Choice D reason:
The introduction of solid foods is recommended to start at around 6 months of age. Starting solid foods at 3 months is too early and can increase the risk of choking and may lead to the development of food allergies.
Correct Answer is D
Explanation
The correct answer is choice D: Document the findings and continue to monitor the client.
Rationale:
Choice A: While encouraging the client to empty her bladder is important to help with uterine contraction, it's not the priority in this situation. The client's fundus is firm and midline, indicating good uterine contraction.
Choice B: Increasing the frequency of fundal massage is not necessary when the fundus is firm and midline. Excessive fundal massage can lead to uterine fatigue and decreased contractility.
Choice C: Notifying the client's provider is not necessary for a moderate amount of lochia rubra and small clots in the early postpartum period. This is a normal finding.
Choice D: Documenting the findings and continuing to monitor the client is the correct action. The nurse should document the amount, color, and consistency of lochia, as well as the fundus assessment. The client should be monitored closely for any signs of excessive bleeding or uterine atony.
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