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A nurse is caring for a client who is in labor and experiences abruptio placenta.

Which of the following findings should the nurse expect?

A.

Hypertension.

B.

Uterine tenderness.

C.

Fetal tachycardia.

D.

Leukorrhea.

Answer and Explanation

The Correct Answer is B

Choice A rationale:
Hypertension is not a typical symptom of abruptio placentae.
Choice B rationale:
Uterine tenderness is a common symptom of abruptio placentae.
Choice C rationale:
Fetal tachycardia is not a typical symptom of abruptio placentae. 
Choice D rationale:
Leukorrhea is not associated with abruptio placentae.

The most likely finding the nurse should expect in a client experiencing abruptio placenta during labor is:

b. Uterine tenderness.

Here's why:

  • Hypertension (a): While preeclampsia can increase the risk of abruptio placenta, it's not always present, and hypertension wouldn't be the immediate expected finding during the abruption event itself.
  • Fetal tachycardia (c): This can occur in early stages of abruption to compensate for decreased oxygen supply, but as the abruption becomes more severe, fetal bradycardia is more likely due to oxygen deprivation.
  • Leukorrhea (d): This is a white vaginal discharge and has no connection to abruptio placenta.

Uterine tenderness is a characteristic sign of abruptio placenta due to bleeding behind the placenta and irritation of the uterine muscle. This is often accompanied by:

  • Vaginal bleeding (bright red or dark)
  • Abdominal pain or cramping
  • Sudden, ongoing uterine tightening or irritability
  • Fetal distress (decreased fetal heart rate movements)

Therefore, option b is the most expected finding in this scenario.

Remember: Early recognition and prompt management of abruptio placenta are crucial for optimal outcomes for both mother and baby. If you suspect abruptio placenta, immediate medical attention is essential.


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Related Questions

Correct Answer is A

Explanation

Choice A rationale:
The client is experiencing postpartum hemorrhage, and the nurse should first collect hemoglobin and hematocrit levels to assess the extent of blood loss.
Choice B rationale:
Inserting an indwelling urinary catheter is not the immediate priority. It may be done later to monitor fluid balance.
Choice C rationale:
Administering oxygen is important, but it’s not the first action. The nurse needs to assess the extent of blood loss first.
Choice D rationale:
Preparing the client to receive a plasma expander is important, but it’s not the first action. The nurse needs to assess the extent of blood loss first.

Correct Answer is B

Explanation

Choice A rationale:
The amount of amniotic fluid around the fetus is determined by an ultrasound, not an indirect Coombs’ test.
Choice B rationale:
The indirect Coombs’ test is used to detect Rh-positive antibodies in the mother’s blood.
Choice C rationale:
The risk of hypoglycemia in the newborn is not determined by the indirect Coombs’ test.
Choice D rationale:
Blood flow in the fetus and placenta is studied using Doppler ultrasound, not an indirect Coombs’ test.

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