A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse recognizes this finding as an indication of which of the following conditions?
Placenta previa.
Preterm labor.
Threatened abortion.
Abruptio placentae.
The Correct Answer is A
Choice A rationale:
Painless, bright red vaginal bleeding at 36 weeks gestation is indicative of placenta previa. Placenta previa is a condition in which the placenta partially or completely covers the cervix, leading to bleeding as the cervix begins to efface and dilate. The bright red color of the blood is due to its fresh origin from the exposed placental vessels. This condition is painless because the bleeding occurs without uterine contractions.
Choice B rationale:
Preterm labor is not the correct answer in this scenario. Preterm labor refers to the onset of regular uterine contractions leading to cervical changes before 37 weeks of gestation. In this case, the key indicator is painless bleeding, which is not associated with uterine contractions.
Choice C rationale:
Threatened abortion is also not the correct answer. Threatened abortion is the term used when a pregnant woman experiences vaginal bleeding, but the cervix is closed, indicating that there is still a chance for the pregnancy to continue. However, the bleeding in placenta previa is unrelated to fetal viability and is specifically caused by the placental position.
Choice D rationale:
Abruptio placentae is not the correct answer either. Abruptio placentae, also known as placental abruption, is a condition where the placenta prematurely separates from the uterine wall before delivery. This can cause painful bleeding due to the blood being trapped between the placenta and uterine wall. In the given scenario, the bleeding is described as painless, which does not align with the characteristics of abruptio placentae.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse should recommend the client to increase cellulose and fluid in the diet. Cellulose is a type of fiber found in fruits, vegetables, and whole grains. Increasing fiber intake can help alleviate constipation by adding bulk to the stool and promoting regular bowel movements. Additionally, the recommendation to increase fluid intake complements the effect of fiber, as it softens the stool, making it easier to pass through the intestines. This combination of increased cellulose and fluid intake is a safe and natural way to address constipation during pregnancy without the need for medication or invasive interventions.
Choice B rationale:
Regular use of glycerine suppositories is not the best recommendation for pregnant clients experiencing constipation. Suppositories are inserted into the rectum to stimulate bowel movements and should only be used sparingly when other methods have failed. Pregnant individuals may have increased sensitivity, and it's essential to avoid unnecessary procedures or potential discomfort.
Choice C rationale:
Regular use of a laxative is also not the most suitable recommendation for a pregnant client with constipation. While laxatives can provide relief, they may lead to dependency and might have adverse effects on the developing fetus. It is best to explore safer and more natural methods before resorting to laxative use during pregnancy.
Choice D rationale:
Maintenance of good posture is essential during pregnancy for various rationales, but it is not a specific solution for constipation. While maintaining good posture can help alleviate back pain and other discomforts, it does not directly address the issue of constipation.
Correct Answer is B
Explanation
Choice A rationale:
Fetal head compression is unlikely to cause variable decelerations in the fetal heart rate. During contractions and labor, the fetal head may experience pressure, but this usually leads to early decelerations, not variable decelerations. Early decelerations are considered benign and are caused by the head's pressure stimulating the vagus nerve, resulting in a temporary decrease in heart rate.
Choice B rationale:
Umbilical cord compression is a known cause of variable decelerations in the fetal heart rate. When the umbilical cord is compressed, it can temporarily disrupt blood flow and oxygen supply to the fetus, leading to decelerations. Variable decelerations often appear as abrupt, sharp drops in the fetal heart rate and are typically characterized by their unpredictable
nature.
Choice C rationale:
Maternal opioid administration is not a direct cause of variable decelerations in the fetal heart rate. While opioids can cross the placenta and may affect the fetus, they are more likely to cause other issues, such as respiratory depression in the newborn, rather than variable decelerations.
Choice D rationale:
Uteroplacental insufficiency is not the primary factor causing variable decelerations. Uteroplacental insufficiency refers to an inadequate blood flow and oxygen delivery to the placenta, which can lead to late decelerations in the fetal heart rate, not variable decelerations.
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