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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The client is experiencing continuous abdominal pain and vaginal bleeding, which are key signs of abruptio placentae. This condition occurs when the placenta prematurely separates from the uterine wall before the baby is born, leading to bleeding and potential fetal distress. The history of cocaine use can be a risk factor for abruptio placentae, as cocaine use may lead to vasoconstriction and reduced blood flow to the placenta.
Choice B rationale:
Hydatidiform mole is not likely in this case because it presents with symptoms such as vaginal bleeding and a "grape-like” mass on ultrasound. The continuous abdominal pain is not typical for a hydatidiform mole.
Choice C rationale:
Preterm labor is not the likely complication in this scenario because the client is at 38 weeks of gestation, which is considered full term. Preterm labor refers to labor that occurs before 37 weeks of gestation.
Choice D rationale:
Placenta previa is not the likely complication as it presents with painless vaginal bleeding in the third trimester, and the abdominal pain described in the question suggests a different condition.
Correct Answer is D
Explanation
Choice A rationale:
Fetal hypoxemia is associated with late decelerations in the fetal heart rate (FHR) tracing. It occurs when the fetus experiences a decreased supply of oxygen, typically due to placental insufficiency or maternal hypotension.
Choice B rationale:
Cord compression can lead to variable decelerations in the FHR tracing. It occurs when the umbilical cord is compressed, restricting blood flow to the fetus temporarily.
Choice C rationale:
Uteroplacental insufficiency causes late decelerations in the FHR tracing. It refers to an inadequate blood flow between the uterus and placenta, resulting in reduced oxygen supply to the fetus.
Choice D rationale:
Head compression is the correct answer for early decelerations in the FHR tracing. It happens during contractions when the fetal head is compressed by the maternal pelvis, leading to a temporary vagal response that slows the heart rate.
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