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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Monitoring cervical dilation is important but not the immediate priority.
B. Asking about the color of the amniotic fluid helps assess for meconium but is secondary.
C. Vaginal pH testing can help confirm rupture but is not the first action.
D. Determining the fetal heart rate is the priority to assess for signs of fetal distress immediately after rupture of membranes.

A. Inactivated influenza B. Human papillomavirus C. Measles, mumps, and rubella D. Varicella E. Diphtheria acellular pertussis

Correct Answer is ["A","E"]

Explanation

A. Inactivated influenza vaccine is safe and recommended during pregnancy to protect both mother and fetus.
B. Human papillomavirus (HPV) vaccine is not recommended during pregnancy.
C. Measles, mumps, and rubella (MMR) vaccine is a live vaccine and contraindicated during pregnancy.
D. Varicella vaccine is live and contraindicated during pregnancy.
E. The Tdap vaccine (diphtheria, acellular pertussis, tetanus) is recommended during each pregnancy, ideally between 27 and 36 weeks gestation to protect the newborn from pertussis.

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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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