A nurse is caring for a client who has an abruptio placentae. Which of the following findings should the nurse expect?
First trimester bleeding
Nausea
Delayed menses
Severe abdominal pain
The Correct Answer is D
Rationale:
A. First trimester bleeding: Abruptio placentae typically occurs in the third trimester, not the first. First trimester bleeding is more commonly associated with conditions like miscarriage or ectopic pregnancy.
B. Nausea: Nausea is a non-specific symptom of pregnancy and not a hallmark of abruptio placentae. It does not help distinguish this condition from other obstetric complications.
C. Delayed menses: Delayed menses is an early sign of pregnancy, not a finding related to abruptio placentae. It occurs long before the placenta forms and has no diagnostic value in placental abruption.
D. Severe abdominal pain: Abruptio placentae involves premature separation of the placenta from the uterine wall, leading to intense, persistent abdominal pain, uterine tenderness, and often vaginal bleeding. It is a medical emergency requiring immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Take your temperature 1 hour after getting out of bed: Delaying temperature measurement can result in inaccurate readings due to physical activity or environmental changes, making it unreliable for detecting ovulation patterns.
B. Take your temperature every night before going to bed: Basal body temperature (BBT) must be taken in the morning, not at night, because the temperature needs to reflect complete rest, which occurs after several hours of sleep.
C. Take your temperature within 30 minutes after your first morning void: Voiding and moving around before taking your temperature can alter the basal reading, reducing the method’s accuracy for predicting fertile days.
D. Take your temperature immediately after waking and before getting out of bed: BBT should be taken at the same time each morning immediately upon waking and before any activity to ensure the most accurate and consistent readings for fertility tracking.
Correct Answer is A
Explanation
Rationale:
A. Weigh the client before and after the procedure: Weighing the client helps to assess the volume of fluid removed and its immediate impact on the client’s body weight. This also assists in evaluating the effectiveness of the procedure and monitoring for fluid imbalances or complications.
B. Administer a low-volume hypertonic enema the night before the procedure: Enemas are not indicated for paracentesis, which involves the peritoneal cavity, not the bowel. Preparing the bowel is not necessary for this procedure and does not influence its safety or effectiveness.
C. Place the client in a side-lying position for the procedure: Paracentesis is typically performed with the client in a semi- to high-Fowler’s position. This position causes ascitic fluid to collect in the lower abdomen, making it more accessible and reducing the risk of organ puncture.
D. Ensure the client has a full bladder just prior to the procedure: The bladder should be emptied before paracentesis to reduce the risk of accidental puncture. A full bladder increases the chance of bladder injury during the needle insertion into the peritoneal cavity.
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