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 C
Explanation
The correct answer is choice C: Respiratory rate.
Choice A rationale:
Fetal heart rate (FHR) is an important assessment for clients experiencing preterm labor, but it is not the priority assessment when administering magnesium sulfate. FHR monitoring is crucial to ensure fetal well-being but is not directly related to the potential adverse effects of magnesium sulfate.
Choice B rationale:
Temperature is an essential assessment parameter, but it is not the priority in this case. Magnesium sulfate administration can cause adverse effects, particularly on the respiratory system, which should be closely monitored.
Choice C rationale:
Respiratory rate is the correct choice because respiratory rate is a priority assessment when administering magnesium sulfate. The drug can cause respiratory depression and other respiratory complications, so monitoring the respiratory rate is essential to ensure the client's safety.
Choice D rationale:
Bowel sounds are not a priority assessment for a client receiving magnesium sulfate. While gastrointestinal side effects can occur with magnesium sulfate use, respiratory assessments take precedence.
In conclusion, the priority nursing assessment for a client receiving magnesium sulfate is the respiratory rate due to the potential respiratory complications associated with the drug. Monitoring respiratory function closely can help prevent adverse outcomes and ensure the client's safety during treatment.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.