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
Explanation
Choice A Reason: This is the correct answer because it is an empathetic and supportive response that acknowledges the client's loss and grief. This is an empathetic and supportive response that acknowledges the client's loss and grief. The other choices are inappropriate because they are insensitive, dismissive, or inaccurate.
Choice B Reason: This is an inappropriate answer because it implies that the nurse does not understand or care about the client's emotional state. It also suggests that the client has no Reason to cry, which is invalidating and hurtful.
Choice C Reason: This is an inappropriate answer because it focuses on the physical pain rather than the emotional pain of the client. It also implies that the nurse wants to avoid dealing with the client's feelings and just give them a medication to make them stop crying.
Choice D Reason: This is an inappropriate answer because it is inaccurate and misleading. A spontaneous abortion, also known as a miscarriage, occurs when a pregnancy ends before 20 weeks of gestation. At this stage, the baby is already formed and has a heartbeat, organs, and limbs. Saying that a baby still wasn't formed in the womb is false and insensitive to the client's loss.
Correct Answer is ["A","B","D"]
Explanation
Choice A Reason: This is correct because breast tenderness is a common discomfort during the first trimester of pregnancy. It is caused by hormonal changes that stimulate breast growth and prepare them for lactation. Breast tenderness may also be accompanied by swelling, tingling, or sensitivity.
Choice B Reason: This is correct because urinary frequency is a common discomfort during the first trimester of pregnancy. It is caused by hormonal changes that increase blood flow to the kidneys and bladder, as well as by the growing uterus that puts pressure on the bladder. Urinary frequency may also be associated with increased thirst or urinary tract infections.
Choice C Reason: This is incorrect because backache is not a common discomfort during the first trimester of pregnancy. It usually occurs in later stages of pregnancy, when the weight of the fetus and the uterus shifts the center of gravity and strains the back muscles and ligaments. Backache may also be caused by poor posture, stress, or fatigue.
Choice D Reason: This is correct because cravings are a common discomfort during the first trimester of pregnancy. They are caused by hormonal changes that affect the sense of taste and smell, as well as by emotional or psychological factors. Cravings may vary from person to person and may include foods that are sweet, salty, sour, or spicy.
Choice E Reason: This is incorrect because leg cramps are not a common discomfort during the first trimester of pregnancy. They usually occur in later stages of pregnancy, when there is increased pressure on the nerves and blood vessels that supply the legs. Leg cramps may also be caused by dehydration, electrolyte imbalance, or muscle fatigue.