A nurse is collecting data from a client who is at 18 weeks of gestation and tells the nurse that she felt light flutering in her stomach the previous day. The nurse should use which of the following terms to document this finding?
Lightening
Chloasma
Ballotement
Quickening
The Correct Answer is D
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Hypertension is the most common risk factor for placental abruption, which occurs when the placenta separates from the uterine wall before delivery. Hypertension can cause damage to the blood vessels that supply the placenta, leading to reduced blood flow and increased pressure in the intervillous space. This can cause hemorrhage and detachment of the placenta.
The other options are not as common as hypertension, but they can also increase the risk of placental abruption by causing trauma, vasoconstriction, or inflammation in the placenta or uterus.
Maternal batering can cause direct injury to the abdomen or uterus, resulting in placental abruption.
Maternal cigarete smoking can cause vasoconstriction and reduced blood flow to the placenta, as well as increase the risk of thrombosis and inflammation in the placental vessels.
d. Maternal cocaine use can cause severe vasoconstriction and hypertension, which can impair placental perfusion and cause placental abruption.
Correct Answer is D
Explanation
The nurse's first action should be to massage the client's fundus, as this can help stimulate uterine contraction and prevent hemorrhage. The fundus is the upper part of the uterus that contracts and involutes after delivery to compress the blood vessels and stop bleeding. The nurse should palpate the fundus for firmness, height, and position, and massage it gently if it is boggy or displaced.
The other actions are not the first priority and may be done after massaging the fundus.
The nurse should observe for the pooling of blood under the buttocks, as this can indicate a large amount of blood loss that may not be visible on the perineal pad. However, this is not the first action to take, as it does not address the cause of the bleeding or stop it from continuing.
The nurse should assess the client's blood pressure, as this can indicate the severity of blood loss and the presence of shock. However, blood pressure may not change significantly until a large amount of blood is lost, and it is not specific to the cause of bleeding. Therefore, blood pressure is not the first action to take.
The nurse should prepare to administer a prescribed oxytocic preparation, such as oxytocin or methylergonovine, as this can enhance uterine contraction and reduce bleeding. However, this requires a provider's order and may take time to obtain and administer. Therefore, an oxytocic preparation is not the first action to take.
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