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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

This is the correct answer. In infants of mothers with poorly controlled diabetes, hyperinsulinemia can lead to increased oxygen consumption and metabolic rate, which can contribute to the development of respiratory distress syndrome.

Choice B rationale

Increased blood viscosity is not the most likely cause of respiratory distress in a macrosomic newborn of a mother with poorly controlled diabetes.

Choice C rationale

A brachial plexus injury is a potential complication of delivery for macrosomic infants, but it is not a cause of respiratory distress syndrome.

Choice D rationale

Increased deposits of fat in the chest and shoulder areas can make delivery more difficult and can increase the risk of birth injuries, but they are not the most likely cause of respiratory distress syndrome in a macrosomic newborn of a mother with poorly controlled diabetes.

A. Fundus at the level of the umbilicus B. Saturated perineal pad in 30 minutes C. Approximated edges of episiotomy D. Deep tendon reflexes 4+

Correct Answer is B

Explanation

Choice A rationale

While the fundus at the level of the umbilicus is a normal finding for a woman who is 4 hours postpartum, it is not the priority in this case. The fundus, which is the top part of the uterus, typically descends at a rate of approximately one fingerbreadth (or one cm) per day, and by the 12th postpartum day, it should no longer be palpable.

Choice B rationale

A saturated perineal pad in 30 minutes is a sign of excessive bleeding, also known as postpartum hemorrhage. This is a serious condition that can lead to shock and other complications if not treated promptly. Therefore, this finding should be prioritized by the nurse.

Choice C rationale

Approximated edges of an episiotomy are a normal finding in the postpartum period. An episiotomy is a surgical incision made in the perineum to enlarge the vaginal opening for delivery. After delivery, the episiotomy is sutured and should heal without complications with proper care. However, this is not the priority finding in this scenario.

Choice D rationale

Deep tendon reflexes 4+ could be a sign of preeclampsia, a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. However, since the client is already 4 hours postpartum, this is less likely to be the priority.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a term macrosomic newborn whose mother has poorly controlled type 2 diabetes. The newborn has respiratory distress syndrome. The nurse should be aware that the most likely cause of the respiratory distress is which of the following?

Correct Answer is A

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is conducting an assessment on a client who is 4 hours postpartum following a vaginal delivery. Which of the following findings should the nurse prioritize?

Correct Answer is B

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is caring for a patient who is at 22 weeks of gestation and has been unable to control her gestational diabetes mellitus with diet and exercise. Which of the following medications should the nurse anticipate the provider will prescribe for the patient?

A nurse is caring for an infant who is receiving phototherapy. Which of the following findings requires intervention by the nurse?

A nurse is caring for a client who gave birth 2 hours ago. The nurse notes that the client’s blood pressure is 60/50 mm Hg. What should be the nurse’s first action?

A nurse is caring for a newborn who is 4 hours old. After reviewing the information in the newborn’s medical record, the nurse should recognize that the newborn is at risk for developing which of the following complications?

A nurse is monitoring a client who is receiving magnesium sulfate to manage preeclampsia. Which of the following observations should the nurse immediately report to the healthcare provider?

A nurse is caring for a client who is suspected to have an ectopic pregnancy at 8 weeks of gestation. What symptoms should the nurse expect to observe that are consistent with this diagnosis?

A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect?