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.
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Related Questions
Correct Answer is B
Explanation
Choice A Reason: Linea nigra is a dark vertical line that appears on the abdomen of some pregnant women. It is caused by increased melanin production and usually fades after delivery.
Choice B Reason: Pica is a condition in which a person has an abnormal desire to eat substances that are not food, such as ice, clay, dirt, or chalk. It is more common in pregnant women and may indicate a deficiency in iron or other nutrients.
Choice C Reason: Ballottement is a technique of palpating a floating structure by bouncing it gently and feeling it rebound. In obstetrics, it can be used to detect the presence of the fetus by feeling its head move when the cervix is tapped.
Choice D Reason: Quickening is the first perception of fetal movements by the pregnant woman. It usually occurs between 16 and 20 weeks of gestation.
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.