A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemia due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons?
The client'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.
The client's blood contains the Rh factor, and the newborn's does not, and antibodies that destroy red blood cells are formed in the fetus.
The client has a history of receiving a transfusion with Rh-negative blood.
The client's anti-A and anti-B antibodies cross the placenta and cause the destruction of the fetal red blood cells.
The Correct Answer is A
Choice A rationale:
Rh incompatibility occurs when an Rh-negative client is exposed to Rh-positive fetal blood, typically during a prior pregnancy or delivery. The client’s immune system produces anti-Rh antibodies that cross the placenta in subsequent pregnancies, attacking the Rh-positive red blood cells of the fetus. This hemolysis releases bilirubin, leading to hyperbilirubinemia in the newborn.
Choice B rationale:
Rh incompatibility only occurs when the client is Rh-negative and the fetus is Rh-positive. An Rh-positive client will not form antibodies against an Rh-negative fetus, as their immune system recognizes the Rh factor as normal.
Choice C rationale:
This choice is not related to the mechanism of Rh incompatibility. Receiving a transfusion with Rh-negative blood would not cause the mother's immune system to produce anti-Rh antibodies or lead to Rh incompatibility with her newborn.
Choice D rationale:
This choice describes the ABO blood group system, not the Rh factor. ABO incompatibility can occur when a mother with blood type O (producing anti-A and anti-B antibodies) has a newborn with blood type A, B, or AB, leading to hemolysis of the fetal red blood cells. However, the question specifically mentions Rh incompatibility, which involves the Rh factor, not the ABO system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The client's statement, "I will check the identification badge of anyone who removes my baby from our room,” indicates an understanding of newborn safety. This statement shows the client's awareness of the importance of verifying the identity of anyone handling their baby before allowing them to be taken out of the room. Checking identification badges helps ensure that only authorized personnel, such as nurses or hospital staff, are allowed to handle the newborn, reducing the risk of unauthorized individuals taking the baby.
Choice B rationale:
This statement is incorrect and does not demonstrate an understanding of newborn safety. Including a photo of the baby along with public birth announcements to social media can compromise the baby's security and privacy. It may expose sensitive information about the baby's location and identity, making the baby vulnerable to potential risks.
Choice C rationale:
This statement is incorrect as it poses a safety risk to the newborn. Allowing the baby to sleep on the bed when the client is in the shower increases the risk of falls or suffocation. The baby should always be placed in a safe sleep environment, such as a crib or bassinet, to minimize the risk of accidents.
Choice D rationale:
This statement is incorrect and does not reflect an understanding of newborn safety. Nurses should not carry the baby in their arms to the nursery. Instead, they should use a crib or an infant carrier to transport the baby safely.
Correct Answer is B
Explanation
Choice A rationale:
Assisting the family in identifying prior coping skills is a valuable nursing intervention, but it is not the priority action in this situation. The client's feelings of sadness and lack of energy raise concerns about postpartum depression, and the nurse should address potential harm to the newborn first.
Choice B rationale:
This is the priority action by the nurse. The client's symptoms are indicative of postpartum depression, and the nurse must assess if she has considered harming her newborn. This assessment is crucial for the safety and well-being of both the mother and the baby.
Choice C rationale:
Anticipating a prescription for an antidepressant may be appropriate once a proper assessment and diagnosis are made, but it is not the priority action at this stage. Assessing for potential harm to the newborn takes precedence.
Choice D rationale:
Reinforcing postpartum and newborn care discharge teaching is essential for the client's well- being. However, it is not the priority action when the client is showing signs of postpartum depression and possible harm to the newborn.
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