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
The correct answer is A. Initiate continuous monitoring of the FHR. For a client with placenta previa, continuous fetal heart rate (FHR) monitoring is essential to assess the baby's well-being due to the risk of fetal distress from reduced oxygen supply
Choice A reason:
Continuous FHR monitoring is a standard care practice for clients with placenta previa to promptly detect any signs of fetal distress and intervene as necessary.
Choice B reason:
Betamethasone is typically administered to enhance fetal lung maturity before 34 weeks of gestation, not for placenta previa. Its use at 35 weeks is less common unless there's a risk of preterm birth within 7 days and the patient hasn't received a previous course.
Choice C reason:
Checking the cervix can induce bleeding and is contraindicated in placenta previa because it may disturb the placental site and exacerbate bleeding.
Choice D reason:
Misoprostol is used for labor induction or to treat postpartum hemorrhage. It is not indicated for placenta previa management and can cause uterine contractions leading to increased bleeding.
Correct Answer is B
Explanation
Assess the fetal heart rate pattern.
Choice B rationale:
When a laboring client's membranes have just ruptured, the nurse's next action should be to assess the fetal heart rate pattern. Rupture of membranes can lead to changes in amniotic fluid, which can affect the fetal environment and potentially cause fetal distress. By assessing the fetal heart rate pattern, the nurse can determine if the baby is tolerating the labor process well or if there are signs of fetal compromise that require further intervention.
Choice A rationale:
While assessing the client's blood pressure (Choice A) is important during labor, it is not the immediate next action when the membranes have ruptured.
Choice C rationale:
Taking the client's temperature (Choice C) is also important, but it is not the priority action when the membranes have ruptured.
Choice D rationale:
Preparing for a c-section (Choice D) is not the initial action unless there are specific indications for an emergency cesarean section. Assessing the fetal heart rate is more critical at this stage.
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