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 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.

A. clear liquid diet B. administration of diethylstilbestrol C. total parenteral nutrition D. nothing by mouth

Correct Answer is C

Explanation

Choice A: A clear liquid diet is not appropriate for a client with hyperemesis gravidarum, which is a severe form of nausea and vomiting during pregnancy that can lead to dehydration, electrolyte imbalance, and weight loss. A clear liquid diet does not provide adequate calories, protein, vitamins, or minerals for the client and the fetus.

Choice B: Administration of diethylstilbestrol is not indicated for a client with hyperemesis gravidarum. Diethylstilbestrol is a synthetic estrogen that was used in the past to prevent miscarriage and premature birth, but it was found to cause serious adverse effects such as vaginal cancer, infertility, and birth defects in the offspring.

Choice C: Total parenteral nutrition is the correct choice because it provides a complete and balanced source of nutrients through a central venous catheter. It is used for clients who cannot tolerate oral or enteral feeding due to severe gastrointestinal disorders such as hyperemesis gravidarum. It helps to prevent malnutrition, dehydration, and ketosis in the client and the fetus.

Choice D: Nothing by mouth is not a suitable option for a client with hyperemesis gravidarum. It can worsen the condition by causing starvation, acidosis, and ketosis. It can also increase the risk of aspiration pneumonia if the client vomits.

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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

During a vaginal exam, the nurse notes that the lower uterine segment is softened. The nurse documents this finding as:

Correct Answer is D

Explanation

A client with hyperemesis gravidarum is admitted to the facility after being cared for at home without success. What would the nurse expect to include in the client's plan of care?

Correct Answer is C

Explanation

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