As the triage nurse in the emergency room, you are reviewing results for the high- risk obstetric client who is in labor because of traumatic injury experienced as a result of a motor vehicle accident (MVA)
You note that the Kleihauer-Betke test is positive. Based on this information, you anticipate that:
a. immediate birth is required.
b. the client should be transferred to the critical care unit for closer observation.
c. RhoGAM should be administered.
d. a tetanus shot should be administered.
ANS: A
A positive Kleihauer-Betke test indicates that fetal bleeding is occurring in the maternal circulation. This is a serious complication and, because the client is a trauma victim, it is highly likely that she is experiencing an abruption. Therefore, the client should be delivered as quickly as possible to improve outcomes. There is no evidence to support that RhoGAM should be administered, because we have no information related to Rh factor and/or blood type. Similarly, a tetanus shot is not indicated at this time because there is no evidence of penetrating trauma. The client should be transferred to the obstetric area for birth, not the critical care unit setting.
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