A nurse is caring for a client who is in labor and experiences abruptio placenta.
Which of the following findings should the nurse expect?
Hypertension.
Uterine tenderness.
Fetal tachycardia.
Leukorrhea.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
A 21-gauge needle is too large for a heel stick on a newborn.
Choice B rationale:
Alcohol can cause skin irritation and should not be used after the procedure.
Choice C rationale:
A warm cloth, not a cool one, should be applied to the site before the procedure to enhance circulation.
Choice D rationale:
The lateral side of the heel is the correct site for a heel stick to avoid injury to the bone.
Correct Answer is D
Explanation
Choice A rationale:
Giving oxytocin 20 units IV bolus is incorrect. Oxytocin is used to stimulate uterine contractions, not to stop bleeding.
Choice B rationale:
Performing a fundal massage is incorrect. This is done to stimulate uterine contractions, not to stop bleeding.
Choice C rationale:
Assessing for abdominal tenderness is incorrect. This is not a priority action when a client is exhibiting a large amount of vaginal bleeding.
Choice D rationale:
Obtaining serial hemoglobin and hematocrit is correct. These lab tests will help determine the extent of blood loss and guide treatment.
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