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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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
Choice A Reason: This is incorrect because ambivalence is a mixed or contradictory feeling towards something or someone. It may occur in some women during pregnancy, especially if the pregnancy was unplanned or unwanted. However, it is not the most likely emotional response in the first trimester.
Choice B Reason: This is correct because emotional lability is a rapid and exaggerated change in mood or affect. It may occur in many women during pregnancy due to hormonal fluctuations, physical changes, and psychological stressors. Emotional lability may manifest as increased irritability, anxiety, sadness, or crying spells.
Choice C Reason: This is incorrect because introversion is a personality trait that indicates a preference for solitude and inward focus. It may be present in some women before or during pregnancy, but it is not an emotional response that is specific to the first trimester.
Choice D Reason: This is incorrect because acceptance is a positive attitude that indicates a willingness to embrace the reality of something or someone. It may develop in some women during pregnancy as they adjust to their new role and identity as mothers. However, it is not the most likely emotional response in the first trimester.