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 A
Explanation
Choice A reason: The mother applying lotion to the newborn's skin requires intervention by the nurse, because it can interfere with the effectiveness of phototherapy and increase the risk of thermal injury. The nurse should instruct the mother to avoid using any lotions, creams, or oils on the newborn's skin during phototherapy.
Choice B reason: The newborn's stools increasing in number does not require intervention by the nurse, because it is a normal and expected outcome of phototherapy. Phototherapy can increase the breakdown and excretion of bilirubin, which can result in more frequent and loose stools.
Choice C reason: A pink rash appearing on the newborn's trunk does not require intervention by the nurse, because it is a common and harmless side effect of phototherapy. The rash usually disappears within a few days after phototherapy is discontinued.
Choice D reason: The newborn's eyes being covered with a mask does not require intervention by the nurse, because it is a standard and essential precaution for phototherapy. The mask protects the newborn's eyes from the harmful effects of the light, such as corneal damage or retinal injury.
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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