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A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemia due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons?

The client's blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns.

The client's blood contains the Rh factor, and the newborn's does not, and antibodies that destroy red blood cells are formed in the fetus.

The client has a history of receiving a transfusion with Rh-negative blood.

The client's anti-A and anti-B antibodies cross the placenta and cause the destruction of the fetal red blood cells.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Rh incompatibility occurs when an Rh-negative client is exposed to Rh-positive fetal blood, typically during a prior pregnancy or delivery. The client’s immune system produces anti-Rh antibodies that cross the placenta in subsequent pregnancies, attacking the Rh-positive red blood cells of the fetus. This hemolysis releases bilirubin, leading to hyperbilirubinemia in the newborn.

Choice B rationale:

Rh incompatibility only occurs when the client is Rh-negative and the fetus is Rh-positive. An Rh-positive client will not form antibodies against an Rh-negative fetus, as their immune system recognizes the Rh factor as normal.

Choice C rationale:

This choice is not related to the mechanism of Rh incompatibility. Receiving a transfusion with Rh-negative blood would not cause the mother's immune system to produce anti-Rh antibodies or lead to Rh incompatibility with her newborn.

Choice D rationale:

This choice describes the ABO blood group system, not the Rh factor. ABO incompatibility can occur when a mother with blood type O (producing anti-A and anti-B antibodies) has a newborn with blood type A, B, or AB, leading to hemolysis of the fetal red blood cells. However, the question specifically mentions Rh incompatibility, which involves the Rh factor, not the ABO system.

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Correct Answer is C

Explanation

Choice A rationale:

Postpartum depression is a more severe and prolonged form of emotional response to childbirth. It involves persistent feelings of sadness, hopelessness, and difficulty bonding with the baby. The symptoms of postpartum depression are different from what the client is experiencing, so this choice is not correct.

Choice B rationale:

The taking-in phase is a normal emotional response to birth, where the mother is focused on her own needs and experiences during the immediate postpartum period. The client's symptoms do not align with this phase, as she is expressing feelings of sadness and crying for no reason.

Choice C rationale:

The postpartum blues, also known as the "baby blues,” is the correct choice. It is a common and transient emotional response to birth experienced by many new mothers. The mother may feel overwhelmed, have mood swings, and cry for no apparent reason. These symptoms usually resolve on their own within a few days to a couple of weeks, and supportive care is typically sufficient.

Choice D rationale:

The taking-hold phase is a phase where the mother becomes more confident in her caregiving abilities and starts to take a more active role in caring for her baby. The client's symptoms do not align with this phase, as she is expressing feelings of sadness and crying for no reason.

A. Vitamin E. B. Vitamin D. C. Fiber. D. Calcium. E. None F. None

Correct Answer is C

Explanation

A. Vitamin E is important for overall health but does not need to be specifically increased during pregnancy.
B. Vitamin D supports calcium absorption, but routine intake is generally sufficient unless a deficiency exists.
C. Fiber intake should be increased during pregnancy to help prevent constipation, which is a common issue due to hormonal changes and slowed gastrointestinal motility.
D. Calcium intake is important, but for many clients, standard dietary recommendations are adequate unless otherwise prescribed.

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A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemia due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons?

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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