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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
To calculate how many capsules to administer per dose, the nurse should divide the ordered dose by the available dose and round to the nearest whole number.
The ordered dose is 50 mg.
The available dose is 25 mg per capsule.
Therefore, the number of capsules to administer per dose is 50 mg / 25 mg = 2 capsules.
The answer should be rounded to the nearest whole number and use a leading zero if it applies. Do not use a trailing zero.
Therefore, the final answer is 2 capsules.
Correct Answer is ["31"]
Explanation
The correct answer is 31 gtts/min. To calculate the infusion rate, the nurse should use the following formula:
Infusion rate (gtts/min) = Volume (mL) x Drop factor (gtts/mL) / Time (min)
Plugging in the given values, we get:
Infusion rate (gtts/min) = 1000 mL x 15 gtts/mL / 480 min
Infusion rate (gtts/min) = 31.25 gtts/min
Rounding to the nearest whole number, we get 31 gtts/min.