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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.

Answer and Explanation

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.

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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.

A. "You should keep the car seat rear-facing until your baby is at least 2 years old.” B. "Position the retainer clip over the upper part of your baby's abdomen.” C. "You should place your baby in the car seat at a 90-degree angle.” D. "Place the shoulder harness straps in the slots an inch above your baby's shoulders.”

Correct Answer is A

Explanation

Choice A rationale:

This is the correct choice. The American Academy of Pediatrics (AAP) recommends keeping children in a rear-facing car seat until they reach the age of 2 or until they reach the maximum weight and height allowed by the car seat's manufacturer. This is because rear- facing seats provide better support for a baby's head, neck, and spine during a crash, reducing the risk of injury.

Choice B rationale:

Placing the retainer clip over the upper part of the baby's abdomen is incorrect and potentially dangerous. The retainer clip should be positioned at armpit level to secure the harness straps properly.

Choice C rationale:

Placing the baby in the car seat at a 90-degree angle is not necessary. The car seat should be installed according to the manufacturer's instructions, and the angle will vary based on the specific car seat model.

Choice D rationale:

Placing the shoulder harness straps in the slots an inch above the baby's shoulders is incorrect. The straps should be positioned at or below the baby's shoulders for rear-facing car seats and at or above the shoulders for forward-facing seats.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down” and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

Correct Answer is B

Explanation

A nurse is teaching the parent of a newborn about car seat safety. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

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