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.

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Correct Answer is A

Explanation

Choice A rationale

Turning the client onto her side is the first action the nurse should take when late decelerations are noted on the fetal monitor. Late decelerations can indicate uteroplacental insufficiency, and turning the client onto her side can improve placental blood flow and oxygen delivery to the fetus.

Choice B rationale

Increasing the client’s IV fluid infusion rate can help increase maternal blood volume and improve placental perfusion. However, it is not the first action to take when late decelerations are noted.

Choice C rationale

Palpating the client’s uterus can provide information about the strength, duration, and frequency of contractions, but it is not the first action to take when late decelerations are noted.

Choice D rationale

Administering oxygen to the client can increase the amount of available oxygen for fetal oxygenation. However, it is not the first action to take when late decelerations are noted.

A. Hyperinsulinemia B. Increased blood viscosity C. Brachial plexus injury D. Increased deposits of fat in the chest and shoulder areas

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.

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Choice B rationale

Choice C rationale

Choice D rationale

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in active labor when the client’s membranes rupture. The fetal monitor tracing shows late decelerations. What is the first action the nurse should take?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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

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