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

Answer and Explanation

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.
Placenta abruption | Pregnancy Birth and Baby

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Correct Answer is B

Explanation

Choice A Reason: This is incorrect because wearing spandex-type full-length pants can constrict the blood flow and increase the swelling in the feet. The nurse should advise the woman to wear loose-fitting clothes and comfortable shoes that do not squeeze or rub her feet.

Choice B Reason: This is correct because elevating the legs when sitting can improve venous return and reduce the swelling in the feet. The nurse should encourage the woman to elevate her legs above her heart level whenever possible and avoid crossing her legs or standing for long periods.

Choice C Reason: This is incorrect because limiting the intake of fluids can cause dehydration and worsen the swelling in the feet. The nurse should recommend the woman drink plenty of water and other healthy fluids to maintain hydration and flush out excess sodium and waste products from her body.

Choice D Reason: This is incorrect because eliminating salt from the diet can cause electrolyte imbalance and affect the fluid balance in the body. The nurse should advise the woman to consume salt in moderation and avoid processed foods that are high in sodium.

A. Recurrent pelvic infections B. Ovarian cyst 2 years ago C. Use of oral contraceptives for 8 years D. Heavy, irregular periods

Correct Answer is A

Explanation

Choice A Reason: This is correct because recurrent pelvic infections, such as pelvic inflammatory disease (PID), can cause scarring and inflammation of the fallopian tubes, which can impair the normal movement of the fertilized egg to the uterus. This can increase the risk of ectopic pregnancy, which is a life-threatening condition where the fertilized egg implants outside the uterine cavity, usually in the fallopian tube.

Choice B Reason: This is incorrect because ovarian cysts are fluid-filled sacs that develop in or on the ovaries. They are usually benign and do not affect fertility or pregnancy. However, some types of ovarian cysts, such as endometriomas or dermoid cysts, may require surgery to remove them, which can cause damage to the ovaries or fallopian tubes and increase the risk of ectopic pregnancy.

Choice C Reason: This is incorrect because use of oral contraceptives for 8 years is not a risk factor for ectopic pregnancy. In fact, oral contraceptives can reduce the risk of ectopic pregnancy by preventing ovulation and fertilization. However, if a woman becomes pregnant while taking oral contraceptives, she should stop taking them and consult her doctor, as they may have adverse effects on the developing fetus.

Choice D Reason: This is incorrect because heavy, irregular periods are not a risk factor for ectopic pregnancy. They may indicate other conditions such as hormonal imbalance, uterine fibroids, polycystic ovary syndrome (PCOS), or endometriosis, which can affect fertility or pregnancy, but not necessarily cause ectopic pregnancy.

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A nurse suspects that a pregnant client may be experiencing placenta abruption based on assessment of which finding? Select all that apply.

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Naxlex Comprehensive Predictor Exams

A pregnant woman in the 36th week of gestation reports that her feet are quite swollen at the end of the day. After careful assessment, the nurse determines that this is an expected finding at this stage of pregnancy. Which intervention is appropriate for the nurse to suggest?

Correct Answer is B

Explanation

Which information on a client's health history would the nurse identify as contributing to the client's risk for an ectopic pregnancy?

Correct Answer is A

Explanation

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