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

Explanation

Choice A reason: Hemorrhage is the most life-threatening complication of a ruptured ectopic pregnancy, as it can lead to hypovolemic shock and death. The nurse should monitor the client's vital signs, blood loss, and level of consciousness, and administer fluids and blood products as ordered.

Choice B reason: Edema is not a common sign of a ruptured ectopic pregnancy, and it is not a priority over hemorrhage. Edema may be caused by other conditions, such as heart failure, kidney disease, or venous insufficiency.

Choice C reason: Infection is a possible complication of a ruptured ectopic pregnancy, but it is not as urgent as hemorrhage. Infection may manifest as fever, chills, malaise, or foul-smelling vaginal discharge. The nurse should administer antibiotics as ordered and monitor the client's temperature and white blood cell count.

Choice D reason: Jaundice is not a typical symptom of a ruptured ectopic pregnancy, and it is not a priority over hemorrhage. Jaundice may indicate liver dysfunction or hemolytic anemia, which are unrelated to ectopic pregnancy. The nurse should assess the client's skin and sclera color, and check the liver enzymes and bilirubin levels.

A. Recurrent pelvic infections B. Ovarian cyst 2 years ago C. Use of oral contraceptives for 8 years D. Heavy, irregular periods

Correct Answer is A

Explanation

Choice A Reason: This is correct because recurrent pelvic infections, such as pelvic inflammatory disease (PID), can cause scarring and inflammation of the fallopian tubes, which can impair the normal movement of the fertilized egg to the uterus. This can increase the risk of ectopic pregnancy, which is a life-threatening condition where the fertilized egg implants outside the uterine cavity, usually in the fallopian tube.

Choice B Reason: This is incorrect because ovarian cysts are fluid-filled sacs that develop in or on the ovaries. They are usually benign and do not affect fertility or pregnancy. However, some types of ovarian cysts, such as endometriomas or dermoid cysts, may require surgery to remove them, which can cause damage to the ovaries or fallopian tubes and increase the risk of ectopic pregnancy.

Choice C Reason: This is incorrect because use of oral contraceptives for 8 years is not a risk factor for ectopic pregnancy. In fact, oral contraceptives can reduce the risk of ectopic pregnancy by preventing ovulation and fertilization. However, if a woman becomes pregnant while taking oral contraceptives, she should stop taking them and consult her doctor, as they may have adverse effects on the developing fetus.

Choice D Reason: This is incorrect because heavy, irregular periods are not a risk factor for ectopic pregnancy. They may indicate other conditions such as hormonal imbalance, uterine fibroids, polycystic ovary syndrome (PCOS), or endometriosis, which can affect fertility or pregnancy, but not necessarily cause ectopic pregnancy.

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 client is suspected of having a ruptured ectopic pregnancy. Which assessment would the nurse identify as the priority?

Correct Answer is A

Explanation

Which information on a client's health history would the nurse identify as contributing to the client's risk for an ectopic pregnancy?

Correct Answer is A

Explanation

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