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 A

Explanation

Choice A Reason: Trisomy numeric abnormality. Down syndrome is a genetic disorder that occurs when a person has three copies of chromosome 21 instead of two. This extra chromosome causes various physical and mental features that vary from person to person. Down syndrome is also called trisomy 21 because it involves three copies of chromosome 21.

Choice B Reason: Multifactorial inheritance is incorrect because it refers to a type of genetic disorder that results from the interaction of multiple genes and environmental factors. Examples of multifactorial disorders include cleft lip or palate, neural tube defects, diabetes, hypertension, and some types of cancer.

Choice C Reason: X-linked recessive inheritance is incorrect because it refers to a type of genetic disorder that affects males more than females because it is caused by a mutation on the X chromosome. Females have two X chromosomes, so they can be carriers or affected depending on whether they inherit one or two copies of the mutated gene. Males have one X chromosome and one Y chromosome, so they are always affected if they inherit the mutated gene from their mother. Examples of X-linked recessive disorders include hemophilia, color blindness, and Duchenne muscular dystrophy.

Choice D Reason: Chromosomal deletion is incorrect because it refers to a type of genetic disorder that occurs when a part of a chromosome is missing or deleted. This can cause various physical and mental problems depending on the size and location of the deletion. Examples of chromosomal deletion

A. Difficulty in arousing B. Deep tendon reflexes 2+ C. Urinary output of 30 mL per hour D. Respiratory rate of 10 breaths/minute

Correct Answer is B

Explanation

Choice A Reason: This is incorrect because difficulty in arousing is a sign of magnesium toxicity, which is a serious complication of magnesium sulfate therapy. Magnesium toxicity can cause central nervous system depression, muscle weakness, and cardiac arrest. The nurse should monitor the client's level of consciousness and stop the infusion if the client becomes lethargic or unresponsive.

Choice B Reason: This is correct because deep tendon reflexes 2+ indicate a normal and expected response to magnesium sulfate therapy. Magnesium sulfate is a muscle relaxant that can reduce the risk of seizures in gestational hypertension. The nurse should assess the client's deep tendon reflexes regularly and maintain them at 2+ or slightly diminished.

Choice C Reason: This is incorrect because urinary output of 30 mL per hour is below the normal range of 40 to 80 mL per hour and may indicate renal impairment or dehydration. Magnesium sulfate can cause renal toxicity or fluid retention, which can affect the urinary output. The nurse should monitor the client's urinary output and fluid balance and report any abnormalities to the doctor.

Choice D Reason: This is incorrect because respiratory rate of 10 breaths/minute is below the normal range of 12 to 20 breaths/minute and may indicate respiratory depression. Magnesium sulfate can cause respiratory depression or failure, which can be life-threatening. The nurse should monitor the client's respiratory rate and oxygen saturation and administer oxygen or antidote if needed.

View Question and Answer

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

While talking with a pregnant woman who has undergone genetic testing, the woman informs the nurse that her baby will be born with Down syndrome. The nurse understands that Down syndrome is an example of:

Correct Answer is A

Explanation

A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. Which finding would the nurse interpret as indicating a therapeutic level of medication?

Correct Answer is B

Explanation

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