The client with blood type O Rh-negative has given birth to an infant with blood type O Rh-positive. The infant has become visibly jaundiced at 12 hours of age. The mother asks why this is happening. The best response by the nurse is:
1. "The RhoGAM you received at 28 weeks' gestation did not prevent alloimmunization."
2. "Your body has made antibodies against the baby's blood that are destroying her red blood cells."
3. "The red blood cells of your baby are breaking down because you both have type O blood."
4. "Your baby's liver is too immature to eliminate the red blood cells that are no longer needed."
2
Rationale:
1. Although this statement is true, the term "alloimmunization" is not likely to be understood by the client. It is better to explain what is happening using more understandable terminology.
2. This is a correct statement.
3. Mother and baby's both having type O blood is not a problem. ABO incompatibility occurs if mother is O and baby is A or B.
4. The infant's liver is indeed too immature to eliminate red blood cells, but the hemolysis from the maternal antibodies is the cause of the jaundice.
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