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:
Desiring privacy with the newborn is not specific to the taking-in phase.
Choice B rationale:
Taking charge of all mothering tasks is more indicative of the taking-hold phase.
Choice C rationale:
Putting personal needs aside is not specific to the taking-in phase.
Choice D rationale:
Reviewing the birth experience with others is characteristic of the taking-in phase.
Correct Answer is C
Explanation
Choice Arationale:
Decreasing the rate of IV fluids would not address the issue of late decelerations, which indicate fetal hypoxia.
Choice Brationale:
Fetal scalp stimulation is used to assess fetal well-being, but it would not address the issue of late decelerations.
Choice C rationale:
Administering oxygen via a face mask can increase the amount of oxygen available to the fetus, potentially alleviating the hypoxia causing the late decelerations.
Choice D rationale:
Elevating the client’s head would not address the issue of late decelerations.
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