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 C

Explanation

Choice A Reason: This is incorrect because gastrointestinal bleeding is not an adverse effect of hydralazine, which is a vasodilator that lowers blood pressure by relaxing the smooth muscles of the blood vessels. Gastrointestinal bleeding can be caused by other conditions such as ulcers, gastritis, or hemorrhoids.

Choice B Reason: This is incorrect because sweating is not an adverse effect of hydralazine, but a normal response to vasodilation and heat loss. Sweating can also be caused by other factors such as fever, anxiety, or exercise.

Choice C Reason: This is correct because tachycardia is an adverse effect of hydralazine, which can occur as a reflex response to vasodilation and hypotension. Tachycardia can increase the cardiac workload and oxygen demand, which can be harmful for pregnant women with preeclampsia who already have impaired placental perfusion and fetal hypoxia.

Choice D Reason: This is incorrect because blurred vision is not an adverse effect of hydralazine, but a symptom of severe preeclampsia that indicates cerebral edema or ischemia. Blurred vision can also be caused by other conditions such as diabetes, glaucoma, or cataracts.

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.

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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 woman hospitalized with severe preeclampsia is being treated with hydralazine to control blood pressure. Which finding would lead the nurse to suspect that the client is having an adverse effect associated with this drug?

Correct Answer is C

Explanation

Correct Answer is ["31"]

Explanation

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