A nurse is caring for a female client who is at 30 weeks of gestation in the labor and delivery unit.
Vaginal bleeding
Uterine contractions
Cervical dilation
Abdominal tenderness
Client report of low back pain
The Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"B,C"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"B,C"}}
Vaginal bleeding
Bleeding occurs in placenta previa due to partial or total implantation of the placenta over the cervical os, leading to painless bright red bleeding from disrupted placental vessels. It also occurs in preterm labor when cervical effacement and dilation disrupt small cervical vessels, producing light bleeding or spotting. In abruptio placenta, bleeding is dark red and may be concealed or apparent, resulting from premature placental detachment and rupture of maternal vessels in the decidua basalis.
Uterine contractions
Regular uterine contractions every 2 to 3 minutes with cervical change are diagnostic of preterm labor, resulting from premature activation of uterine oxytocin receptors and prostaglandin release before 37 weeks. In abruptio placenta, contractions are often strong and sustained (hypertonic uterus) due to myometrial irritability from bleeding into the decidual layer. Placenta previa, however, typically presents with painless bleeding and a soft, relaxed uterus without contractions because the uterine muscle tone remains unaffected.
Cervical dilation
Cervical dilation indicates preterm labor, as biochemical changes in the cervix from increased prostaglandin and relaxin activity cause collagen breakdown and effacement before term. This process reflects uterine activation sequence initiation leading to potential preterm birth. In placenta previa, the cervix may remain closed despite bleeding because bleeding originates from placental implantation, not cervical change. Abruptio placenta rarely involves dilation unless labor progresses secondarily after placental separation, thus cervical dilation is not a key feature.
Abdominal tenderness
Abdominal tenderness is characteristic of abruptio placenta, caused by bleeding between the uterine wall and placenta leading to myometrial irritability, uterine rigidity, and ischemic pain. The trapped blood increases intrauterine pressure, stimulating pain receptors in the myometrium and stretching the uterine serosa. Placenta previa presents with a soft, nontender abdomen because bleeding is external and not associated with uterine muscle involvement. Preterm labor generally causes back discomfort or cramping, not localized abdominal tenderness.
Client report of low back pain
Low back pain is prominent in preterm labor, resulting from referred pain due to rhythmic uterine contractions transmitted through the lumbosacral plexus and pelvic nerves. It reflects early cervical change and uterine irritability. In abruptio placenta, the back pain may occur secondary to uteroplacental separation and posterior placental bleeding irritating the parietal peritoneum. Placenta previa typically lacks pain or back discomfort since bleeding occurs without uterine or peritoneal irritation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Subconjunctival hemorrhage is a common, generally benign finding in newborns, often resulting from increased intraocular pressure during the birthing process, causing rupture of superficial capillaries in the sclera. It presents as a bright red patch under the conjunctiva and usually resolves spontaneously within a few weeks without intervention, thus it does not warrant immediate, priority assessment.
Choice B rationale
Rust-stained urine, or pink-tinged urine, in a newborn is typically due to the presence of uric acid crystals (urates) in the urine, a normal finding related to concentrated urine and the immaturity of the newborn kidney's ability to concentrate urine fully. This is a common, non-pathological observation in the first few days of life, indicating mild dehydration, but it is not an acute, high-priority concern.
Choice C rationale
Nasal flaring is a significant sign of respiratory distress in a newborn, indicating the infant is attempting to increase the diameter of the nasal passages to decrease airway resistance and enhance the intake of oxygen. This compensatory mechanism suggests compromised gas exchange and potential hypoxemia, requiring immediate assessment and intervention to prevent further respiratory compromise.
Choice D rationale
Overlapping suture lines, also known as molding, occurs when the cranial bones shift and overlap during passage through the narrow birth canal. This is a normal, expected finding, especially after a vaginal delivery, and the shape of the head typically returns to normal within a few days to a week, posing no immediate threat to the newborn.
Correct Answer is C
Explanation
Choice A rationale
Limiting visitors solely to immediate family is a hospital policy matter and while it may reduce traffic, it does not directly address the active physical security measures necessary to prevent infant abduction, which relies on a multi-faceted approach including staff vigilance, electronic systems, and parent education.
Choice B rationale
Sending the newborn to the nursery is a practice that increases the distance between the parent and the infant, potentially decreasing immediate parental observation and vigilance. Current best practices emphasize "rooming-in" to keep the newborn at the bedside, promoting bonding and constant parental awareness of the infant's whereabouts.
Choice C rationale
Checking identification badges of staff is a critical, active security measure that empowers parents as the final checkpoint in infant protection, ensuring only authorized and verifiable personnel handle the newborn. This reduces the risk of abduction by individuals impersonating hospital staff.
Choice D rationale
The electronic monitoring band is a vital part of the hospital's security system, often triggering an alarm if the infant is moved near an exit or beyond a designated area. Removing this band at any time, even for bathing, compromises the continuous electronic surveillance and increases the risk of abduction.
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