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.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A rationale

Chorioamnionitis. Based on the information provided, the patient is at risk of developing chorioamnionitis, which is an infection of the membranes surrounding the fetus.

Choice B rationale

Preeclampsia. There is no information provided that would indicate the patient is at risk of developing preeclampsia.

Choice C rationale

Gestational diabetes. There is no information provided that would indicate the patient is at risk of developing gestational diabetes.

Choice D rationale

Preterm labor. There is no information provided that would indicate the patient is at risk of developing preterm labor.

A. Perineal pad clots B. Pelvic pain C. Boggy uterus D. Breast Engorgement

Correct Answer is C

Explanation

Choice A rationale:
Perineal pad clots are not the greatest risk for this patient. While it’s important to monitor the amount and type of lochia, the nurse’s notes indicate that the patient has a moderate amount of lochia rubra, which is normal within the first few days postpartum. Large clots could indicate a problem such as a retained placental fragment, but this is not mentioned in
the scenario.
Choice B rationale:
Pelvic pain is a common complaint after childbirth due to uterine contractions, especially during breastfeeding, and usually resolves within a few days. The patient’s pain is rated as 4 on a scale of 0 to 10, which is considered moderate. While it’s important to manage the patient’s pain, it’s not the greatest risk in this scenario.
Choice C rationale:
A boggy uterus poses the greatest risk for this patient. A boggy or soft uterus indicates uterine atony, which is a lack of normal muscle tone that can lead to excessive bleeding. This is a serious condition that can lead to postpartum hemorrhage if not treated promptly. The nurse’s notes indicate that the patient’s fundus is boggy and located above the umbilicus, which is a concern. The fundus should be firm and gradually descend into the pelvis within the first few days postpartum.
Choice D rationale:
Breast engorgement is a common discomfort that occurs when the breasts are overly full with milk. It typically occurs within the first week postpartum as the milk supply increases. The nurse’s notes indicate that the patient’s breasts are soft, warm, and tender to touch, which is normal. While it’s important to manage the patient’s comfort, breast
engorgement is not the greatest risk in this scenario.

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Choice B rationale

Choice C rationale

Choice D rationale

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Naxlex Comprehensive Predictor Exams

A nurse is providing care for a patient who is in labor. After reviewing the patient’s medical history, vital signs, nurse’s notes, and diagnostic results, which of the following complications should the nurse identify that the patient is at risk of developing?

Correct Answer is A

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is caring for a patient who is 36 hours postpartum. Exhibits After reviewing the information in the patient’s medical record, which of the following complications pose a greater risk for the patient?

Correct Answer is C

Explanation

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