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."

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Administering oxygen via nasal cannula is not a necessary intervention for the client, unless she has signs of hypoxia, such as dyspnea, tachypnea, or cyanosis. Oxygen administration is not routinely indicated for clients with inevitable abortion.

Choice B reason: Offering option to view products of conception is an appropriate intervention for the client, because it can help her cope with the loss of pregnancy and facilitate the grieving process. The nurse should respect the client's decision and provide emotional support.

Choice C reason: Instructing the client to increase potassium-rich foods in the diet is not a relevant intervention for the client, unless she has signs of hypokalemia, such as muscle weakness, cramps, or arrhythmias. Potassium intake is not related to the cause or prevention of inevitable abortion.

Choice D reason: Maintaining the client in a Trendelenburg position is not a recommended intervention for the client, because it can increase the risk of aspiration, respiratory compromise, and venous congestion. Trendelenburg position is not effective in preventing or treating inevitable abortion.

A. Irregular fetal heart rate B. Rapid decline in human chorionic gonadotropin (hCG) levels C. Profuse, clear vaginal discharge D. Excessive uterine enlargement

Correct Answer is D

Explanation

Choice A reason: Irregular fetal heart rate is not an expected finding in a client with a hydatidiform mole, as it can indicate fetal arrhythmia, distress, or demise. A client with a hydatidiform mole may have no fetal heart tones, as the pregnancy is nonviable and consists of abnormal trophoblastic tissue.

Choice B reason: Rapid decline in human chorionic gonadotropin (hCG) levels is not an expected finding in a client with a hydatidiform mole, as it can indicate a normal or abnormal termination of pregnancy. A client with a hydatidiform mole may have markedly elevated hCG levels, as the trophoblastic tissue secretes excessive amounts of the hormone.

Choice C reason: Profuse, clear vaginal discharge is not an expected finding in a client with a hydatidiform mole, as it can indicate a normal or abnormal cervical mucus production. A client with a hydatidiform mole may have vaginal bleeding, which is often dark brown or bright red, and may contain grape-like vesicles.

Choice D reason: Excessive uterine enlargement is an expected finding in a client with a hydatidiform mole, as it reflects the rapid growth of the trophoblastic tissue and the accumulation of fluid-filled vesicles. A client with a hydatidiform mole may have a uterus that is larger than expected for the gestational age, and may experience uterine cramping or pain.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is at 10 weeks of gestation and reports abdominal pain and moderate vaginal bleeding. The tentative diagnosis is inevitable abortion. Which of the following nursing interventions should be included in the plan of care?

Correct Answer is B

Explanation

A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client?

Correct Answer is D

Explanation

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