A nurse is assessing a client who has a grade 2 placental abruption.
Which of the following findings should the nurse expect?

Fetal heart rate of 150/min with moderate variability.

Painless vaginal bleeding.

Soft abdomen.

Heart rate 120/min.

Answer and Explanation

The Correct Answer is D

Choice A rationale

A fetal heart rate (FHR) of 150/min with moderate variability is within the normal range (110-160/min) and suggests adequate fetal oxygenation, which is less indicative of a significant Grade 2 abruption. A Grade 2 (moderate) abruption typically involves 20%-50% placental separation, often resulting in fetal distress like persistent late decelerations or tachycardia as a compensatory response to hypoxemia.

Choice B rationale

Placenta previa, not abruption, classically presents with painless, bright red vaginal bleeding due to the placenta covering the cervical os. Placental abruption, caused by premature separation of the placenta from the uterine wall, typically causes bleeding accompanied by significant, severe, and unrelenting abdominal pain due to concealed hemorrhage and uterine irritability.

Choice C rationale

A soft abdomen suggests a relaxed uterus, which is normal. In Grade 2 placental abruption, blood often becomes trapped between the placenta and uterine wall, causing uterine tetany or hypertonicity (increased muscle tone) and rigidity, which presents as a firm or board-like abdomen that is tender to palpation.

Choice D rationale

A heart rate of 120/min (tachycardia) in the client is an expected finding in a moderate (Grade 2) placental abruption. The client is experiencing hypovolemia due to hemorrhage (internal and/or external bleeding), which triggers a compensatory sympathetic nervous system response, increasing the heart rate to maintain cardiac output and tissue perfusion.

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Correct Answer is C

Explanation

Choice A rationale: Trendelenburg position, where the client is placed with the head lower than the feet, is not appropriate in this scenario. This position is typically used for procedures requiring pelvic exposure or in cases of air embolism. It does not optimize uteroplacental perfusion and may actually compromise maternal respiratory function in late pregnancy due to diaphragmatic pressure from the gravid uterus. Therefore, it is not the correct position following prostaglandin insertion.

Choice B rationale: Knee-chest position is used in obstetric emergencies such as umbilical cord prolapse to relieve pressure on the cord and improve fetal oxygenation. It is not indicated for cervical ripening or for optimizing uteroplacental perfusion. Maintaining this position would be uncomfortable and unnecessary for the client, and it does not aid in medication absorption. Thus, it is not the correct intervention in this context.

Choice C rationale: Lateral tilt, specifically left lateral or side-lying tilt, is the correct position. This position reduces compression of the inferior vena cava by the gravid uterus, thereby improving venous return, cardiac output, and uteroplacental perfusion. It also facilitates optimal absorption of the vaginal prostaglandin insert by keeping the medication in place. This is the evidence-based nursing intervention following prostaglandin administration for cervical ripening.

Choice D rationale: Lithotomy position is used primarily for vaginal examinations, procedures, or delivery. It is not appropriate for maintaining medication absorption or optimizing uteroplacental perfusion. Prolonged lithotomy positioning increases maternal discomfort and risk of venous stasis. Since the client is not undergoing delivery or a procedure requiring pelvic exposure, this position is not indicated after prostaglandin insertion.

A. Taking antiviral medications will cure the condition. B. HSV-2 is not harmful to a developing fetus. C. Transmission to the newborn is higher if lesions are present at birth. D. Wear tight-fitting undergarments when lesions are present.

Correct Answer is C

Explanation

Choice A rationale

Although antiviral medications such as acyclovir or valacyclovir can suppress viral replication and reduce the frequency, duration, and severity of outbreaks, they do not eliminate the virus from the body. Genital herpes simplex virus (HSV-2) infection is a chronic, lifelong condition for which there is currently no known cure, therefore, medication will only manage the symptoms.

Choice B rationale

Genital herpes simplex virus (HSV-2) can be transmitted vertically from mother to fetus or newborn, particularly during a primary infection in pregnancy or during vaginal birth. Neonatal herpes infection can be severe or fatal, causing disseminated disease, central nervous system involvement, or mucocutaneous lesions, thus, it is a significant risk to the developing fetus/newborn.

Choice C rationale

The risk of neonatal transmission of HSV-2 is significantly higher (around 25.

Choice D rationale

Wearing tight-fitting undergarments can increase heat and moisture in the genital area, leading to friction and irritation of the lesions, which can prolong healing and increase discomfort during an outbreak. Clients are advised to wear loose-fitting cotton undergarments to keep the area dry and promote air circulation, which helps with lesion healing.

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A nurse is assessing a client who has a grade 2 placental abruption. Which of the following findings should the nurse expect?

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A nurse is assessing a client who has a grade 2 placental abruption.
Which of the following findings should the nurse expect?