A nurse is assessing a client who has a grade 2 placental abruption. Which of the following findings should the nurse expect?
Soft abdomen
Heart rate 120/min
A fetal heart of 150/min with moderate variability
Painless vaginal bleeding
The Correct Answer is B
A. A grade 2 placental abruption typically presents with a firm or rigid abdomen due to concealed bleeding, not a soft one.
B. Maternal tachycardia (heart rate 120/min) is expected due to blood loss and compensatory response to hypovolemia.
C. A fetal heart rate of 150/min with moderate variability is a reassuring sign and would not typically be expected in a significant abruption, where fetal distress is more common.
D. Vaginal bleeding from placental abruption is typically painful, and may be concealed. Painless bleeding is more characteristic of placenta previa.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. It is normal for the newborn’s cord stump to remain attached for up to 1-2 weeks.
B. Newborns typically sleep 16-20 hours per day, so this is expected.
C. Fewer than four wet diapers in 24 hours can indicate inadequate hydration or feeding and requires immediate evaluation.
D. Loose stools are common in breastfed newborns and are generally not concerning.
Correct Answer is B
Explanation
A. Nausea is a common and generally mild side effect of oral contraceptives and does not typically require immediate medical attention.
B. Persistent headaches may indicate an increased risk of stroke or hypertension, especially in clients with other risk factors. This could be a sign of a serious adverse effect and should be reported to the provider immediately.
C. Breast tenderness is a common and usually benign side effect of hormonal contraceptives.
D. Abdominal bloating may occur but is not typically dangerous or an urgent concern.
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