A nurse in a provider's office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?
Cigarette smoking
Hypertension
Blunt force trauma
Cocaine use
The Correct Answer is B
Choice A rationale
This is incorrect because cigarette smoking is not the most common risk factor for abruption. Cigarette smoking can increase the risk of abruption by causing vasoconstriction and reducing placental blood flow, but it is less prevalent and less severe than hypertension.
Choice B rationale
This is correct because hypertension is the most common risk factor for abruption. Hypertension can cause damage to the uterine vessels and lead to bleeding and separation of the placenta from the uterine wall. Hypertension affects about 40% of clients who experience abruption and can be chronic or pregnancy-induced.
Choice C rationale
This is incorrect because blunt force trauma is not the most common risk factor for abruption. Blunt force trauma can cause abruption by applying direct pressure or shear force to the placenta, but it is less common and less predictable than hypertension. Blunt force trauma can result from motor vehicle accidents, falls, or physical abuse.
Choice D rationale
This is incorrect because cocaine use is not the most common risk factor for abruption. Cocaine use can increase the risk of abruption by causing vasoconstriction and uterine contractions, but it is less common and less consistent than hypertension. Cocaine use can also cause other complications, such as fetal growth restriction, preterm labor, or stillbirth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
This is incorrect because a client who has missed a period and reports vaginal spotting is not the most urgent case. This could indicate a possible pregnancy or a menstrual irregularity, but it is not a life-threatening condition. The nurse should see this client after assessing the other clients.
Choice B rationale
This is correct because a client who is at 28 weeks of gestation and reports painless vaginal bleeding is the most urgent case. This could indicate a placenta previa, which is a condition where the placenta covers the cervical opening and can cause severe hemorrhage and fetal distress. The nurse should see this client immediately and prepare for an emergency cesarean section.
Choice C rationale
This is incorrect because a client who is at 38 weeks of gestation and reports a cough and fever is not the most urgent case. This could indicate a respiratory infection, which can affect the maternal and fetal well-being, but it is not a life-threatening condition. The nurse should see this client after assessing the other clients and administer antibiotics and antipyretics as prescribed.
Choice D rationale
This is incorrect because a client who is at 14 weeks of gestation and reports nausea and vomiting is not the most urgent case. This could indicate a normal pregnancy symptom or a hyperemesis gravidarum, which is a condition where the nausea and vomiting are severe and persistent. The nurse should see this client after assessing the other clients and provide hydration and antiemetics as prescribed.
Correct Answer is C
Explanation
Choice A rationale
Changing the client's position is not the first action the nurse should take. Changing the client's position may improve the blood flow and oxygen delivery to the placenta and the fetus, but it is not the most urgent intervention. The nurse should change the client's position after administering oxygen and notifying the provider.
Choice B rationale
Applying a fetal scalp electrode is not the first action the nurse should take. Applying a fetal scalp electrode may provide a more accurate and continuous monitoring of the FHR, but it is not the most urgent intervention. The nurse should apply a fetal scalp electrode only if the external monitor is not reliable or if the provider orders it.
Choice C rationale
Administering oxygen at 10 L/min via a nonrebreather mask is the first action the nurse should take. Administering oxygen is the most urgent intervention to increase the oxygen saturation and prevent fetal hypoxia. Late decelerations are a sign of uteroplacental insufficiency, which means that the placenta is not delivering enough oxygen to the fetus. The nurse should administer oxygen and notify the provider immediately.
Choice D rationale
Increasing the rate of the IV infusion is not the first action the nurse should take. Increasing the rate of the IV infusion may improve the blood volume and perfusion to the placenta and the fetus, but it is not the most urgent intervention. The nurse should increase the rate of the IV infusion after administering oxygen and notifying the provider.
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