A nurse is caring for a client who is at 36 weeks of gestation and has suspected placenta previa. For which of the following findings should the nurse monitor the client?
Abdominal pain with minimal red vaginal bleeding.
A large amount of bright red vaginal bleeding without pain.
Severe abdominal pain with increasing fundal height.
Intermittent abdominal pain following the passage of bloody mucus.
The Correct Answer is B
Choice A rationale:
Abdominal pain with minimal red vaginal bleeding may not be as concerning as other options. While it could be a sign of placenta previa, it is not as specific or significant as the finding in Choice B.
Choice B rationale:
A large amount of bright red vaginal bleeding without pain is a significant finding that is highly suggestive of placenta previa. Placenta previa occurs when the placenta partially or completely covers the cervix, and vaginal bleeding is a common symptom. The bright red colour indicates active bleeding, and the absence of pain is noteworthy as placenta previa bleeding is typically painless.
Choice C rationale:
Severe abdominal pain with increasing fundal height is not a typical sign of placenta previa. While abdominal pain can be associated with various pregnancy complications, it is not a specific finding for this condition.
Choice D rationale:
Intermittent abdominal pain following the passage of bloody mucus could be related to other issues, such as preterm labor or cervical changes. While bleeding may be present in placenta previa, the pain and passage of mucus are not characteristic features of this condition.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Hypotension is not an expected finding in a client with severe preeclampsia. In preeclampsia, the client typically experiences hypertension (high blood pressure) rather than hypotension (low blood pressure). Hypotension may be concerning as it could indicate inadequate perfusion to vital organs.
Choice B rationale:
Headache is an expected finding in a client with severe preeclampsia. Headaches are a common symptom of preeclampsia and are often described as persistent and severe. They can result from increased blood pressure and possibly cerebral oedema.
Choice C rationale:
Tachycardia is not an expected finding in a client with severe preeclampsia. Tachycardia refers to an abnormally fast heart rate, but in preeclampsia, bradycardia (abnormally slow heart rate) or a normal heart rate is more typical. Tachycardia could indicate other underlying issues.
Choice D rationale:
Polyuria is not an expected finding in a client with severe preeclampsia. Polyuria is characterized by excessive urination, and in preeclampsia, the opposite may occur due to decreased kidney perfusion, resulting in oliguria (reduced urine output).
Correct Answer is A
Explanation
The correct answer is choice A: Respiratory rate of 16/min.
Choice A rationale:
A respiratory rate of 16/min is within the normal range for adults, which is typically between 12 to 20 breaths per minute. In the context of severe preeclampsia, maintaining a normal respiratory rate is crucial when administering magnesium sulfate IV, as one of the signs of magnesium toxicity is respiratory depression. Therefore, a respiratory rate of 16/min indicates that the client is not experiencing respiratory depression and it is safe to continue the magnesium sulfate infusion.
Choice B rationale:
A heart rate of 60/min is at the lower end of the normal range, which is 60 to 100 beats per minute for adults. However, bradycardia or a low heart rate can be a sign of magnesium sulfate toxicity, especially if accompanied by other symptoms such as hypotension or altered mental status. Without additional context, a heart rate of 60/min alone does not necessarily indicate it is unsafe to continue the infusion, but it would require further assessment.
Choice C rationale:
A urine output of 50 mL in 4 hours is significantly below the expected minimum of 30 mL/hour for adults. Adequate urine output is an important indicator of kidney function and is essential for the excretion of magnesium. In the case of magnesium sulfate infusion for severe preeclampsia, a low urine output could indicate renal insufficiency and an increased risk of magnesium toxicity. Therefore, a urine output of 50 mL in 4 hours is a contraindication for continuing the infusion without further evaluation.
Choice D rationale:
Diminished deep-tendon reflexes can be a sign of magnesium toxicity. Deep-tendon reflexes are assessed to monitor for signs of magnesium overdose during infusion, as magnesium acts as a central nervous system depressant at high levels. If deep-tendon reflexes are diminished, it may suggest that the serum magnesium levels are too high, and the infusion should be paused or discontinued to prevent further toxicity.
In summary, the only finding that clearly indicates it is safe to continue the magnesium sulfate infusion is a normal respiratory rate, as provided in choice A. The other options either require further assessment or are indicators of potential magnesium toxicity.
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