A nurse is providing care for a patient who has recently given birth to her first child. The patient has a history of receiving a transfusion with Rh-negative blood.
The nurse expects hyperbilirubinemia due to Rh incompatibility.
What is the reason for hyperbilirubinemia occurring with Rh incompatibility?
The nurse expects hyperbilirubinemia due to Rh incompatibility.
Gastrointestinal assessment findings.
Respiratory rate.
Deep tendon reflexes.
The Correct Answer is C
Choice A rationale
The patient’s anti-A and anti-B antibodies crossing the placenta and causing the destruction of the fetal red blood cells is related to ABO incompatibility, not Rh incompatibility.
Choice B rationale
If the patient’s blood contains the Rh factor and the newborn’s does not, Rh incompatibility would not occur. Rh incompatibility happens when the mother’s blood does not contain the Rh factor (Rh-negative), but the baby’s blood does contain the Rh factor (Rh-positive).
Choice C rationale
The patient’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. This is the correct reason for hyperbilirubinemia occurring with Rh incompatibility.
Choice D rationale
The patient’s blood containing anti-Rh antibodies that attack the newborn’s red blood cells is a result of Rh incompatibility, but it does not explain why hyperbilirubinemia occurs.
Hyperbilirubinemia occurs due to the breakdown of the extra red blood cells, leading to an increase in bilirubin levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Intermittent abdominal pain following the passage of bloody mucus can be a sign of labor or other complications, but it is not a typical finding that supports the diagnosis of placenta previa.
Choice B rationale
Painless red vaginal bleeding is a classic symptom of placenta previa. This occurs because the placenta is covering part or all of the cervix, leading to bleeding as the cervix begins to thin and open in preparation for labor.
Choice C rationale
Abdominal pain with scant red vaginal bleeding could indicate various conditions, but it is not a typical finding that supports the diagnosis of placenta previa.
Choice D rationale
Increasing abdominal pain with a non-relaxed uterus could indicate various conditions, but it is not a typical finding that supports the diagnosis of placenta previa.
Correct Answer is A
Explanation
Choice A rationale
Applying lotion to the newborn’s skin during phototherapy is not recommended. Lotion can block the light from reaching the skin and reduce the effectiveness of the treatment.
Choice B rationale
Covering the newborn’s eyes with a mask during phototherapy is a standard practice. This is done to protect the newborn’s eyes from the intense light used in phototherapy.
Choice C rationale
An increase in stool frequency is expected during phototherapy. This is because phototherapy helps to break down bilirubin, which is then excreted in the stool.
Choice D rationale
A pink rash on the newborn’s trunk does not require intervention during phototherapy. It could be a common newborn rash that will resolve on its own.
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