A nurse is providing teaching to a client about the purpose of her upcoming indirect Coombs' test. Which of the following statements should the nurse include in the teaching?
"This test determines if your baby is at risk for developing hypoglycemia after birth.".
"This test will determine the amount of amniotic fluid around the fetus.".
"This test studies blood flow in the fetus and placenta using ultrasound waves.".
"This test will detect the presence of Rh-positive antibodies in your blood."
The Correct Answer is D
Choice A rationale:
This statement is incorrect. An indirect Coombs' test is not used to determine the risk of hypoglycemia in a baby after birth. It is used to detect antibodies against red blood cells, particularly in the context of blood incompatibility between a pregnant woman and her fetus.
Choice B rationale:
This statement is incorrect. An indirect Coombs' test is not related to determining the amount of amniotic fluid around the fetus. It is used primarily to assess for Rh incompatibility between the mother and fetus.
Choice C rationale:
This statement is incorrect. The test described here is a Doppler ultrasound, not an indirect Coombs' test. Doppler ultrasound is used to study blood flow in the fetus and placenta using ultrasound waves.
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Correct Answer is D
Explanation
Choice A rationale:
To calculate the estimated date of delivery using Nägele's Rule, subtract three months from the first day of the last menstrual period (August 10), and then add seven days. However, choice A (May 20) is incorrect because it adds eight days instead of seven.
Choice B rationale:
It does not add seven days to the calculation.
Choice C rationale:
It adds three days instead of seven to the calculation
Choice D rationale:
It follows the correct application of Nägele's Rule. Subtracting three months from August 10 gives us May 10, and then adding seven days gives us May 17as the estimated date of delivery.
Correct Answer is C
Explanation
Choice Arationale:
Offering the client a sitz bath may provide some relief, but it does not address the underlying issue of bladder distention. The priority is to address the bladder distention directly.
Choice Brationale:
Inserting a urinary catheter is not the first-line intervention for bladder distention after vaginal birth. Catheterization carries a risk of infection and trauma, so it should only be done if other interventions are not effective.
Choice C rationale:
Assisting the client to the bathroom is the first action the nurse should take. Bladder distention can occur after birth due to the pressure on the bladder during labour and birth. Encouraging the client to empty her bladder will relieve the distention and promote comfort.
Choice D rationale:
Pouring warm water over the client's perineum might provide some comfort, but it does not address the bladder distention itself.
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