A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications?
Preeclampsia
Anaphylactoid syndrome of pregnancy
Disseminated intravascular coagulation
Puerperal infection
The Correct Answer is C
Choice A: This is incorrect because preeclampsia is a condition characterized by hypertension, proteinuria, and edema that occurs after 20 weeks of gestation. It is not related to abruptio placentae, which is the premature separation of the placenta from the uterine wall. Preeclampsia does not cause petechiae or bleeding around the IV site, but it may cause headache, blurred vision, epigastric pain, or seizures.
Choice B: This is incorrect because anaphylactoid syndrome of pregnancy, also known as amniotic fluid embolism, is a rare and life-threatening complication that occurs when amniotic fluid enters the maternal circulation and triggers an allergic reaction. It is not related to abruptio placentae, but it may occur during labor, delivery, or shortly after birth. Anaphylactoid syndrome of pregnancy does not cause petechiae or bleeding around the IV site, but it may cause respiratory distress, hypotension, cardiac arrest, or disseminated intravascular coagulation.
Choice C: This is the correct answer because disseminated intravascular coagulation (DIC) is a condition in which the blood clotting system is activated abnormally, leading to excessive clot formation and consumption of clotting factors and platelets. This results in bleeding from various sites, such as the IV site, gums, nose, or vagina. DIC is a common complication of abruptio placentae, as the release of thromboplastin from the placenta triggers the clotting cascade. DIC can also cause organ failure, shock, or death if not treated promptly.
Choice D: This is incorrect because puerperal infection, also known as postpartum infection, is a bacterial infection that affects the uterus, vagina, bladder, or wound site after childbirth. It is not related to abruptio placentae, but it may occur due to prolonged labor, cesarean delivery, retained placenta, or poor hygiene. Puerperal infection does not cause petechiae or bleeding around the IV site, but it may cause fever, malaise, foul-smelling lochia, or pelvic pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice a) 100 to 120 is incorrect because this is too low for a normal newborn's heart rate. The heart rate of a newborn is influenced by factors such as gestational age, activity level, temperature, and health status. A full-term, quiet, alert newborn should have a heart rate between 120 and 160 beats per minute, which reflects their high metabolic rate and oxygen demand. A heart rate below 100 beats per minute may indicate bradycardia, which can be caused by hypoxia, hypothermia, or cardiac problems.
Choice b) 120 to 160 is correct because this is the normal range for a full-term, quiet, alert newborn's heart rate. The apical pulse is the best way to measure the heart rate of a newborn, as it reflects the actual contractions of the heart. The apical pulse can be auscultated at the fourth intercostal space on the left side of the chest, just below the nipple line. The nurse should count the apical pulse for a full minute, as it may vary with the respiratory cycle.
Choice c) 80 to 100 is incorrect because this is also too low for a normal newborn's heart rate. A full-term, quiet, alert newborn should have a heart rate between 120 and 160 beats per minute, which is higher than that of an adult or an older child. A heart rate below 100 beats per minute may indicate bradycardia, which can be caused by hypoxia, hypothermia, or cardiac problems.
Choice d) 150 to 180 is incorrect because this is too high for a normal newborn's heart rate. A full-term, quiet, alert newborn should have a heart rate between 120 and 160 beats per minute, which is lower than that of a preterm or a crying newborn. A heart rate above 160 beats per minute may indicate tachycardia, which can be caused by fever, infection, anemia, or hyperthyroidism.
Correct Answer is D
Explanation
Choice A) Weight gain of 0.5 kg during the past 2 weeks: This is a normal weight gain for a pregnant woman and does not indicate preeclampsia.
Choice B) Pitting pedal edema at the end of the day: This is a common symptom of pregnancy and does not necessarily indicate preeclampsia. It can be relieved by elevating the legs and wearing compression stockings.
Choice C) Blood pressure increase to 138/86 mm Hg: This is a mild elevation of blood pressure and does not meet the criteria for preeclampsia, which is defined as a systolic blood pressure of 140 mm Hg or higher or a diastolic blood pressure of 90 mm Hg or higher on two occasions at least four hours apart.
Choice D) Dipstick value of 3+ for protein in her urine: This is a sign of significant proteinuria, which is one of the main features of preeclampsia. Proteinuria is defined as a urinary protein excretion of 300 mg or more in 24 hours or a dipstick reading of 1+ or higher. A dipstick value of 3+ indicates severe proteinuria and requires immediate attention and treatment. This woman has the highest risk of developing complications from preeclampsia, such as eclampsia, HELLP syndrome, placental abruption, or fetal growth restriction . Therefore, she should be seen by the nurse first.
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