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 B
Explanation
Choice A Reason: This is incorrect because ambivalence is a mixed or contradictory feeling towards something or someone. It may occur in some women during pregnancy, especially if the pregnancy was unplanned or unwanted. However, it is not the most likely emotional response in the first trimester.
Choice B Reason: This is correct because emotional lability is a rapid and exaggerated change in mood or affect. It may occur in many women during pregnancy due to hormonal fluctuations, physical changes, and psychological stressors. Emotional lability may manifest as increased irritability, anxiety, sadness, or crying spells.
Choice C Reason: This is incorrect because introversion is a personality trait that indicates a preference for solitude and inward focus. It may be present in some women before or during pregnancy, but it is not an emotional response that is specific to the first trimester.
Choice D Reason: This is incorrect because acceptance is a positive attitude that indicates a willingness to embrace the reality of something or someone. It may develop in some women during pregnancy as they adjust to their new role and identity as mothers. However, it is not the most likely emotional response in the first trimester.
Correct Answer is B
Explanation
Choice A Reason: Nagele's rule is a formula that estimates the due date by subtracting three months from the first day of the last menstrual period and adding seven days. However, this method assumes a regular 28-day cycle and may not be accurate for women with irregular cycles or who are unsure of their last menstrual period.
Choice B Reason: Ultrasound is the most accurate method of determining the estimated due date, especially in the first trimester. Ultrasound uses sound waves to create an image of the fetus and measure its size and development. Ultrasound can also detect any abnormalities or complications that may affect the pregnancy.
Choice C Reason: Gestation wheel is a circular calendar that estimates the due date by aligning the first day of the last menstrual period with a corresponding date on the wheel. However, this method also assumes a regular 28-day cycle and may not account for variations in ovulation or implantation.
Choice D Reason: Birth calculator is an online tool that estimates the due date based on various factors such as the last menstrual period, cycle length, ovulation date, conception date, or ultrasound date. However, this method may not be reliable as it depends on the accuracy of the input data and the algorithm used by the calculator.
