A nurse is caring for a client who is 6 hr 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 determines the presence of maternal antibodies in the newborn's blood."
"It determines if kernicterus will occur in the newborn."
"It detects Rh-positive antibodies in the mother's blood."
"It detects Rh-negative antibodies in the newborn's blood."
The Correct Answer is C
Choice A reason: This statement is incorrect, as it describes the direct Coombs test, not the indirect Coombs test. The direct Coombs test is performed on the newborn's blood, and it detects the presence of maternal antibodies that have attached to the newborn's red blood cells. The direct Coombs test can help diagnose hemolytic disease of the newborn, which is a condition where the maternal antibodies destroy the newborn's red blood cells, causing anemia and jaundice.
Choice B reason: This statement is incorrect, as it is not the purpose of the indirect Coombs test, but rather a possible complication of hemolytic disease of the newborn. Kernicterus is a severe form of jaundice that occurs when the bilirubin level in the blood is very high, and it can cause brain damage, deafness, or death. Kernicterus can be prevented by treating the jaundice with phototherapy or exchange transfusion.
Choice C reason: This statement is correct, as it describes the indirect Coombs test, which is performed on the mother's blood, and it detects the presence of Rh-positive antibodies that have formed in response to the exposure to the Rh-positive blood of the newborn. The indirect Coombs test can help identify the risk of hemolytic disease of the newborn, and guide the administration of Rh immunoglobulin, which is a medication that prevents the formation of Rh-positive antibodies.
Choice D reason: This statement is incorrect, as it is not possible for the newborn to have Rh-negative antibodies, since the newborn has Rh-positive blood. Rh-negative antibodies are produced by Rh-negative individuals who have been exposed to Rh-positive blood, such as Rh-negative mothers who have Rh-positive newborns. Rh-negative antibodies can cross the placenta and attack the Rh-positive red blood cells of the newborn, causing hemolytic disease of the newborn.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Polyuria is not an expected finding in a client with severe preeclampsia, as it can indicate dehydration, diabetes, or renal impairment. A client with severe preeclampsia may have oliguria, which is a urine output of less than 500 mL in 24 hours, due to the decreased renal perfusion and function.
Choice B reason: Report of headache is an expected finding in a client with severe preeclampsia, as it can indicate increased intracranial pressure, cerebral edema, or vasospasm. A client with severe preeclampsia may also have other neurological symptoms, such as blurred vision, scotoma, photophobia, or hyperreflexia.
Choice C reason: Tachycardia is not an expected finding in a client with severe preeclampsia, as it can indicate dehydration, infection, anxiety, or fetal distress. A client with severe preeclampsia may have bradycardia, which is a heart rate of less than 60 beats per minute, due to the increased vagal tone and blood pressure.
Choice D reason: Absence of clonus is not an expected finding in a client with severe preeclampsia, as it can indicate normal or decreased neuromuscular irritability. A client with severe preeclampsia may have positive clonus, which is a rhythmic jerking of the foot when the ankle is dorsiflexed, due to the increased reflex excitability and hyperactivity.
Correct Answer is A
Explanation
Choice A reason: This statement is correct, as the ultrasound can help diagnose placenta previa, which is a condition where the placenta covers the cervical opening and can cause painless, bright red bleeding in the third trimester. Placenta previa is a serious complication that can affect the delivery and the fetal oxygenation.
Choice B reason: This statement is incorrect, as the biparietal diameter is a measurement of the fetal head that is used to estimate the gestational age and the fetal growth. The biparietal diameter is not related to the cause or the severity of the bleeding.
Choice C reason: This statement is incorrect, as the fetal lung maturity is an assessment of the surfactant level in the amniotic fluid that is used to predict the risk of respiratory distress syndrome in preterm infants. The fetal lung maturity is not related to the cause or the severity of the bleeding.
Choice D reason: This statement is incorrect, as the viability of the fetus is an evaluation of the fetal heart rate, movement, and tone that is used to determine the fetal well-being and distress. The viability of the fetus is not related to the cause or the severity of the bleeding, although it can be affected by it.
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