An infant with type O Rh-positive blood becomes visibly jaundiced at 12 hours of age. The mother with type O Rh-negative blood asks why this has occurred. How should the nurse respond?
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
Explanation:
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. Alloimmune hemolytic disease, also known as erythroblastosis fetalis, occurs when an Rh-negative mother is pregnant with an Rh-positive fetus and maternal antibodies cross the placenta. Maternal antibodies enter the fetal circulation, then attach to and destroy the fetal RBCs. The fetal system responds by increasing RBC production. Jaundice is the result.
3. Mother and baby's both having type O blood is not a problem. ABO incompatibility occurs if the mother is O and the 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.
You might also like to view...
After teaching a group of parents about language development in toddlers, which of the following if stated by a member of the group indicates successful teaching?
A) "When my 3-year-old asks 'why?' all the time, this is completely normal." B) "A 15-month-old should be able to point to his eyes when asked to do so." C) "At age 2 years, my son should be able to understand things like under or on." D) "An 18-month-old would most likely use words and gestures to communicate."
A home care nurse is teaching a patient's daughter meal planning for her mother who is recovering from a hip replacement surgery
Which of the following meals indicates that the daughter understands the concept of a nutritionally complete choice based upon the Food Guide Pyramid? A) Cheeseburger, carrot sticks and mushroom soup with crackers B) Spaghetti and meat sauce with a salad C) Chicken and pepper stir fry and basmati rice D) Ham sandwich with tomato on rye bread with peaches and yogurt
A nurse is caring for a client with complaints of frequent urination. When assessing the urinalysis report, the nurse should look for what component to confirm a normal urinalysis?
A) A specific gravity of 1.030 to 1.050 B) A pH level ranging from 12 to 16 C) Absence of glucose in the urine D) Presence of red blood cells (RBCs)
The nurse is reviewing a patient's assessment data upon admission to the acute care facility. Which finding best indicates iron deficiency anemia?
a. Pulse of 90 beats/min b. Yellow sclera c. Tea-colored urine d. Pale conjunctivae