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","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 ["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.

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

A nurse is assessing a client who may be pregnant. The nurse reviews the client's history for presumptive signs. Which signs would the nurse most likely note? Select all that apply.

Correct Answer is ["A","B","C","E"]

Explanation

Correct Answer is ["31"]

Explanation

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