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: Vitamin E requirements do not decrease during pregnancy due to the increase in body fat. Vitamin E is a fat-soluble vitamin that acts as an antioxidant and protects cell membranes from oxidative damage. The recommended dietary allowance (RDA) for vitamin E during pregnancy is 15 mg/day, which is the same as for non-pregnant women.
Choice B: Prenatal vitamins will meet your need for increased folic acid during pregnancy. Folic acid is a water-soluble vitamin that is essential for DNA synthesis and cell division. Folic acid deficiency can cause neural tube defects in the fetus, such as spina bifida and anencephaly. The RDA for folic acid during pregnancy is 600 mcg/day, which can be obtained from prenatal vitamins and fortified foods.
Choice C: You will not need to double your intake of protein during pregnancy. Protein is a macronutrient that provides amino acids for tissue growth and repair. The RDA for protein during pregnancy is 1.1 g/kg/day, which is only slightly higher than for non-pregnant women (0.8 g/kg/day).
Choice D: You will not need to increase your intake of calcium during pregnancy. Calcium is a mineral that is important for bone health and muscle contraction. Calcium absorption and retention are enhanced during pregnancy, so there is no need to increase the intake above the RDA of 1000 mg/day for women aged 19 to 50 years.
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because Ortolani's sign is a test for hip dysplasia in infants, not a sign of pregnancy. It involves moving the infant's legs to check for a clicking sound in the hip joint.
Choice B Reason: This is incorrect because Chadwick's sign is a bluish or purplish discoloration of the cervix, vagina, and vulva during pregnancy, not a softening of the lower uterine segment. It is caused by increased blood flow to the pelvic area.
Choice C Reason: This is incorrect because Goodell's sign is a softening of the cervix during pregnancy, not a softening of the lower uterine segment. It is caused by increased vascularity and edema of the cervical tissue.
Choice D Reason: This is correct because Hegar's sign is a softening of the lower uterine segment or isthmus during pregnancy. It can be felt by bimanual examination around six to twelve weeks of gestation.