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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While itching can be a side effect of opioid analgesics, it is not the priority observation. Itching can be uncomfortable for the client, but it is not life-threatening.
Choice B rationale
A temperature of 38.2°C (100.8°F) indicates a low-grade fever. While this should be monitored, it is not the priority observation in this situation.
Choice C rationale
The priority observation is the client’s blood pressure. Opioid epidural analgesia can cause hypotension, which can lead to inadequate perfusion to the mother and the fetus. Therefore, the nurse should prioritize monitoring the client’s blood pressure.
Choice D rationale
Weakness of the lower extremities can be a side effect of epidural analgesia, but it is not the priority observation. The nurse should monitor for this, but it is not as critical as monitoring the client’s blood pressure.
Correct Answer is D
Explanation
Choice A rationale
Perinatal asphyxia refers to a lack of oxygen flow to the fetus around the time of birth. This can lead to multiple organ dysfunction and neurological issues, but it is not a common cause of a newborn being small for gestational age.
Choice B rationale
Preterm delivery can result in a newborn being small for their gestational age simply because they have not had the full amount of time to grow in the womb. However, preterm babies are typically compared to other preterm babies when assessing size, not to full-term babies.
Choice C rationale
Fetal hyperinsulinemia, or an excess of insulin in the fetus, can lead to excessive growth and a larger-than-average baby size (macrosomia), not a smaller size.
Choice D rationale
Placental insufficiency, where the placenta does not work as well as it should, can limit the amount of oxygen and nutrients the fetus receives. This can restrict the baby’s growth, leading to a small size for gestational age.
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