A nurse suspects that a pregnant client may be experiencing placenta abruption based on assessment of which finding? Select all that apply.
Absence of pain
Insidious onset
Dark red vaginal bleeding
Rigid uterus
Correct Answer : C,D,E
Choice A: Absence of pain is not a sign of abruptio placenta. Abruptio placenta is a condition where the placenta separates from the uterine wall before delivery, causing bleeding and pain. The pain is usually severe and constant.
Choice B: Insidious onset is not a sign of abruptio placenta. Abruptio placenta is usually a sudden and acute event that occurs in the third trimester or during labor.
Choice C: Dark red vaginal bleeding is a sign of abruptio placenta. The bleeding is caused by the rupture of blood vessels between the placenta and the uterus. The blood may be dark red because it is old or clotted.
Choice D: Rigid uterus is a sign of abruptio placenta. The uterus becomes hard and tense as a result of the bleeding and contraction of the uterine muscles. This can impair the blood flow to the fetus and cause fetal distress.
Choice E: Absent fetal heart tones is a sign of abruptio placenta. The loss of blood and oxygen to the fetus can cause fetal death or stillbirth. Fetal heart tones can be detected by using a Doppler device or a fetoscope.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because sickle-cell anemia is a genetic disorder that affects the shape and function of red blood cells. It does not affect the AFP level, which is a protein produced by the fetus and placenta. Sickle-cell anemia can be detected by other prenatal tests, such as hemoglobin electrophoresis or DNA analysis.
Choice B Reason: This is incorrect because cardiac defects are structural abnormalities of the heart or blood vessels that affect the blood flow and oxygen delivery to the fetus. They may cause an increased AFP level, not a decreased one, as they can lead to fetal distress or edema. Cardiac defects can be detected by other prenatal tests, such as fetal echocardiography or ultrasound.
Choice C Reason: This is correct because Down syndrome is a chromosomal disorder that results from an extra copy of chromosome 21. It causes various physical and mental developmental delays and defects in the fetus. It is associated with a decreased AFP level, as well as decreased levels of human chorionic gonadotropin (hCG) and unconjugated estriol (uE3). Down syndrome can be confirmed by other prenatal tests, such as amniocentesis or chorionic villus sampling (CVS).
Choice D Reason: This is incorrect because respiratory disorders are problems that affect the breathing and gas exchange of the fetus. They may cause an increased AFP level, not a decreased one, as they can lead to fetal distress or edema. Respiratory disorders can be detected by other prenatal tests, such as fetal biophysical profile (BPP) or nonstress test (NST).
Correct Answer is A
Explanation
Choice A Reason: This is the correct answer because it is an empathetic and supportive response that acknowledges the client's loss and grief. This is an empathetic and supportive response that acknowledges the client's loss and grief. The other choices are inappropriate because they are insensitive, dismissive, or inaccurate.
Choice B Reason: This is an inappropriate answer because it implies that the nurse does not understand or care about the client's emotional state. It also suggests that the client has no Reason to cry, which is invalidating and hurtful.
Choice C Reason: This is an inappropriate answer because it focuses on the physical pain rather than the emotional pain of the client. It also implies that the nurse wants to avoid dealing with the client's feelings and just give them a medication to make them stop crying.
Choice D Reason: This is an inappropriate answer because it is inaccurate and misleading. A spontaneous abortion, also known as a miscarriage, occurs when a pregnancy ends before 20 weeks of gestation. At this stage, the baby is already formed and has a heartbeat, organs, and limbs. Saying that a baby still wasn't formed in the womb is false and insensitive to the client's loss.