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.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: The rubella vaccine is a live attenuated virus vaccine, which is generally not recommended during pregnancy due to the theoretical risk to the fetus. However, it is safe to receive the rubella vaccine while breastfeeding; it does not pose a risk to the nursing infant.
Choice B reason: The varicella vaccine, which is also a live virus vaccine, should not be administered during pregnancy because of the potential risk to the fetus. Women should be vaccinated before pregnancy or in the postpartum period.
Choice C reason: The Tdap vaccine, which protects against tetanus, diphtheria, and pertussis (whooping cough), is recommended for all pregnant women during each pregnancy, regardless of their previous history of receiving the vaccine. The optimal timing for Tdap administration is between 27 and 36 weeks of gestation to maximize the transfer of antibodies to the baby.
Choice D reason: Pregnant women are encouraged to receive the inactivated influenza vaccine at any point during their pregnancy. The flu shot is safe during pregnancy and helps protect both the mother and the baby from the flu and its complications.
Correct Answer is C
Explanation
Choice A reason:
Inserting an indwelling urinary catheter can be helpful in measuring urine output and reducing bladder distention, which may impede uterine contractions. However, it is not the immediate next step in managing postpartum hemorrhage.
Choice B reason:
Administering oxytocin by continuous IV infusion is a standard intervention to promote uterine contractions after delivery, which helps to control bleeding. However, before starting an oxytocin infusion, it is important to ensure that there are no retained placental fragments and that the uterus is not already well-contracted.
Choice C reason:
Massaging the client's fundus is the priority action because it can stimulate uterine contractions, which are essential for controlling postpartum bleeding. A firm, contracted uterus helps to compress the blood vessels and prevent excessive bleeding.
Choice D reason:
Tilting the client onto her right side with her legs elevated can help improve venous return and may be part of the management for shock. However, the immediate concern in a postpartum client with excessive bleeding is to manage the bleeding by promoting uterine contractions.
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