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 A
Explanation
Choice A rationale
Elevating the leg can help reduce swelling and improve blood flow, which can alleviate pain and redness in the calf. This is a non-pharmacological intervention that the client can easily do at home.
Choice B rationale
Applying cold compresses is typically used for acute injuries to reduce inflammation and numb the area. However, in the case of a postpartum client reporting pain and redness in her calf, this could potentially be a sign of a deep vein thrombosis (DVT), and applying cold compresses may not be the most appropriate intervention.
Choice C rationale
Flexing the knee while resting is not typically recommended for a client with symptoms that may indicate a DVT. This position does not promote venous return and could potentially exacerbate the condition.
Choice D rationale
Massaging the area is not recommended if a DVT is suspected, as it could dislodge a blood clot and cause a pulmonary embolism.
Correct Answer is A
Explanation
The correct answer is Choice A........ Therefore, it poses the greatest risk to a newborn who is 30
minutes old.
Choice B rationale
Birth weight can influence a newborn’s health, with low birth weight associated with various health problems. However, it is less immediately life-threatening compared to meconium aspiration syndrome.
Choice C rationale
Gestational age can influence a newborn’s health, with preterm birth associated with various health problems. However, it is less immediately life-threatening compared to meconium aspiration syndrome.
Choice D rationale
Fetal Undergrowth Anomaly (FUA) refers to a condition where a fetus does not grow at the expected rate during pregnancy. It can lead to various health problems for the newborn. However, it is less immediately life-threatening compared to meconium aspiration syndrome.
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