which of the following statements about rh incompatibility is true

HESI LPN

HESI Maternal Newborn

1. Which of the following statements about Rh incompatibility is true?

A. Rh incompatibility occurs most commonly during a woman’s first pregnancy.
B. Rh incompatibility is an untreatable condition that leaves a woman infertile for the rest of her life.
C. Rh incompatibility is an abnormality that is transmitted from generation to generation and carried by a sex chromosome.
D. Rh incompatibility occurs due to antibodies transmitted to a fetus during subsequent deliveries causing brain damage or death.

Correct answer: D

Rationale: Rh incompatibility occurs when the mother's antibodies attack the fetus's red blood cells, leading to serious complications, usually in subsequent pregnancies. Choice A is incorrect because Rh incompatibility often occurs in subsequent pregnancies, not necessarily the first one. Choice B is incorrect as Rh incompatibility does not render a woman infertile but can lead to complications during pregnancies. Choice C is incorrect as Rh incompatibility is not carried by a sex chromosome but involves the Rh factor on red blood cells.

2. A perinatal nurse is caring for a woman in the immediate postpartum period. Assessment reveals that the client is experiencing profuse bleeding. What is the most likely cause of this bleeding?

A. Uterine atony.
B. Uterine inversion.
C. Vaginal hematoma.
D. Vaginal laceration.

Correct answer: A

Rationale: Uterine atony is significant hypotonia of the uterus and is the leading cause of postpartum hemorrhage. It results in the inability of the uterus to contract effectively after delivery, leading to excessive bleeding. Uterine inversion is a rare but serious complication that involves the turning inside out of the uterus, leading to hemorrhage, but it is not the most likely cause of profuse bleeding in this scenario. Vaginal hematoma may cause bleeding but is typically associated with pain as a primary symptom rather than profuse bleeding. Vaginal lacerations can cause bleeding, but in the presence of a firm, contracted uterine fundus, uterine atony is a more likely cause of ongoing profuse bleeding in the postpartum period.

3. Which of the following statements is true about Tay-Sachs disease?

A. It is most commonly found among children in Jewish families of Eastern European background.
B. Children who have this disease suffer from excessive production of mucus in the lungs and pancreas.
C. It is most commonly found among children in Asian American families.
D. Children who have this disease suffer from muscular dystrophy characterized by a weakening of the muscles.

Correct answer: A

Rationale: The correct answer is A. Tay-Sachs disease is most commonly found among Jewish families of Eastern European descent. It is a fatal genetic disorder that affects the nervous system. Choice B is incorrect because Tay-Sachs disease does not involve excessive mucus production in the lungs and pancreas. Choice C is incorrect as it states that Tay-Sachs disease is most commonly found among Asian American families, which is inaccurate. Choice D is also incorrect because Tay-Sachs disease does not cause muscular dystrophy characterized by weakening of the muscles.

4. A client is in the second stage of labor. Which of the following manifestations should the nurse expect?

A. The client expels the placenta
B. The client experiences gradual dilation of the cervix
C. The client begins having regular contractions
D. The client delivers the newborn

Correct answer: D

Rationale: During the second stage of labor, the cervix is fully dilated, and the client delivers the newborn. The expulsion of the placenta occurs during the third stage of labor, not the second stage. Regular contractions typically begin in the first stage of labor, not the second. Gradual dilation of the cervix occurs during the first stage of labor, specifically during the active phase.

5. What nursing action should the nurse implement for a 3-hour-old male infant who presents with cyanotic hands and feet, an axillary temperature of 96.5°F (35.8°C), a respiratory rate of 40 breaths per minute, and a heart rate of 165 beats per minute?

A. Administer oxygen by mouth at 2L/min
B. Gradually warm the infant under a radiant heat source
C. Notify the pediatrician of the infant's vital signs
D. Perform a heel-stick to maintain blood glucose levels

Correct answer: B

Rationale: The correct nursing action is to gradually warm the infant under a radiant heat source. The infant is presenting with signs of cold stress, indicated by cyanotic extremities and a low body temperature. Gradual warming is crucial to stabilize the infant's temperature and prevent further complications. Administering oxygen, notifying the pediatrician, or performing a heel-stick are not the priority actions in this scenario and may not address the immediate need to raise the infant's body temperature.