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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While congenital anomalies, growth restriction, and fetal distress during labor can occur in pregnancies, they are not directly associated with polyhydramnios. Polyhydramnios is a condition characterized by an excessive accumulation of amniotic fluid in the uterus during pregnancy.
Choice B rationale
Carrying more than one fetus can lead to a condition known as twin-to-twin transfusion syndrome, which can result in polyhydramnios in one twin and oligohydramnios in the other. However, carrying more than one fetus does not directly mean the mother will experience polyhydramnios.
Choice C rationale
Polyhydramnios is indeed characterized by an excessive amount of amniotic fluid present in the uterus during pregnancy. This can be due to various reasons such as fetal abnormalities, maternal diabetes, and others.
Choice D rationale
An elevated level of alpha-fetoprotein (AFP) in the amniotic fluid can be an indication of certain fetal abnormalities, but it is not a direct indicator of polyhydramnios.
Correct Answer is B
Explanation
Choice A rationale
Turning the newborn on his side is a good practice to prevent aspiration, but it is not the first action to take. The newborn’s airway must be clear first to ensure proper breathing.
Choice B rationale
Suctioning the mouth with a bulb syringe is the priority action when a newborn has secretions bubbling out of the nose and mouth. This action helps clear the airway and allows the newborn to breathe more easily.
Choice C rationale
Suctioning the nose with a bulb syringe is also important, but the mouth should be suctioned first. This is because the newborn could aspirate oral secretions during inhalation if the mouth is not suctioned first.
Choice D rationale
Using a suction catheter with low negative pressure is not the first action to take. A bulb syringe is usually sufficient to clear the newborn’s airway of secretions.
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