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 D
Explanation
Choice A: 28 weeks' gestation is too early to screen for group B streptococcus infection. Group B streptococcus (GBS) is a type of bacteria that can cause serious infections in newborns if transmitted from the mother during labor and delivery. The optimal time to screen for GBS is between 35 and 37 weeks' gestation.
Choice B: 32 weeks' gestation is also too early to screen for GBS infection. Screening at this time may not reflect the true colonization status of the mother at the time of delivery, as GBS can be transient or intermittent.
Choice C: 16 weeks' gestation is much too early to screen for GBS infection. Screening at this time has no clinical value, as GBS colonization can change throughout pregnancy.
Choice D: 36 weeks' gestation is the appropriate time to screen for GBS infection. Screening at this time can identify mothers who are colonized with GBS and who need intrapartum antibiotic prophylaxis to prevent neonatal sepsis, pneumonia, and meningitis.
Correct Answer is B
Explanation
Choice A Reason: This is incorrect because marijuana is a psychoactive substance that affects the central nervous system and can cause euphoria, relaxation, altered perception, and impaired memory. It does not cause tachycardia, hypertension, or vasoconstriction in pregnant women or their fetuses.
Choice B Reason: This is correct because cocaine is a stimulant substance that affects the cardiovascular system and can cause tachycardia, hypertension, vasoconstriction, arrhythmias, and ischemia in pregnant women or their fetuses. It can also increase the risk of placental abruption, preterm labor, intrauterine growth restriction, and fetal death.
Choice C Reason: This is incorrect because nicotine is a stimulant substance that affects the respiratory system and can cause bronchodilation, increased heart rate, and increased blood pressure in pregnant women or their fetuses. However, it does not cause vasoconstriction, but rather vasodilation.
Choice D Reason: This is incorrect because caffeine is a stimulant substance that affects the central nervous system and can cause alertness, insomnia, anxiety, and increased urine output in pregnant women or their fetuses. It does not cause tachycardia, hypertension, or vasoconstriction in moderate doses.
Choice E Reason: This is incorrect because heroin is an opioid substance that affects the central nervous system and can cause euphoria, sedation, analgesia, and respiratory depression in pregnant women or their fetuses. It does not cause tachycardia, hypertension, or vasoconstriction.
