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 ["A","B","C","E"]
Explanation
Choice A Reason: Nausea is a common presumptive sign of pregnancy, especially in the first trimester. It is caused by hormonal changes and may be accompanied by vomiting.
Choice B Reason: Abdominal enlargement is another presumptive sign of pregnancy, as the uterus grows to accommodate the developing fetus. It may be noticeable as early as 12 weeks of gestation.
Choice C Reason: A positive pregnancy test is a presumptive sign of pregnancy, as it detects the presence of human chorionic gonadotropin (hCG), a hormone produced by the placenta. However, it is not a definitive sign, as it may be affected by other factors such as medications, tumors, or false positives.
Choice D Reason: Braxton Hicks contractions are not a presumptive sign of pregnancy, but a probable sign. They are irregular and painless contractions of the uterus that occur throughout pregnancy, but become more frequent and noticeable in the third trimester. They are also known as false labor contractions.
Choice E Reason: Amenorrhea, or the absence of menstrual periods, is a presumptive sign of pregnancy, as it indicates that ovulation has ceased. However, it is not a definitive sign, as it may be caused by other factors such as stress, illness, or hormonal imbalances.
Correct Answer is B
Explanation
Choice A Reason: Nagele's rule is a formula that estimates the due date by subtracting three months from the first day of the last menstrual period and adding seven days. However, this method assumes a regular 28-day cycle and may not be accurate for women with irregular cycles or who are unsure of their last menstrual period.
Choice B Reason: Ultrasound is the most accurate method of determining the estimated due date, especially in the first trimester. Ultrasound uses sound waves to create an image of the fetus and measure its size and development. Ultrasound can also detect any abnormalities or complications that may affect the pregnancy.
Choice C Reason: Gestation wheel is a circular calendar that estimates the due date by aligning the first day of the last menstrual period with a corresponding date on the wheel. However, this method also assumes a regular 28-day cycle and may not account for variations in ovulation or implantation.
Choice D Reason: Birth calculator is an online tool that estimates the due date based on various factors such as the last menstrual period, cycle length, ovulation date, conception date, or ultrasound date. However, this method may not be reliable as it depends on the accuracy of the input data and the algorithm used by the calculator.
