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 B
Explanation
Choice A rationale:
Assessing for bladder distention is important for postpartum clients, especially those who have undergone perineal trauma during childbirth. However, it is not the priority assessment during a sitz bath. The sitz bath is usually done to promote healing and comfort, and monitoring pulse rate takes precedence to identify any adverse reactions.
Choice B rationale:
Pulse rate should be the priority assessment during a sitz bath for a postpartum client. Sitz baths can cause vasodilation, leading to a potential drop in blood pressure, increased heart rate, or dizziness. Monitoring the pulse rate helps identify any cardiovascular changes or adverse reactions.
Choice C rationale:
Respiratory rate is not the priority assessment during a sitz bath. It is essential to monitor, but it is less likely to be affected directly by the sitz bath compared to the pulse rate and cardiovascular changes.
Choice D rationale:
Monitoring the color of lochia is essential for assessing postpartum bleeding and uterine healing. However, during a sitz bath, the priority assessment should be focused on cardiovascular changes and any adverse reactions the client might experience.
Correct Answer is D
Explanation
A. Vitamin E requirements do not significantly increase during pregnancy.
B. While vitamin D is important for calcium absorption, the recommended intake does not increase during pregnancy.
C. Fiber intake is beneficial for digestion but does not have increased requirements specific to pregnancy.
D. Calcium intake should be increased to support fetal bone and teeth development.
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