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: Hemodilution of pregnancy is a normal physiological phenomenon that occurs when the plasma volume increases more than the red blood cell mass, resulting in a lower hemoglobin concentration. The normal hemoglobin range for pregnant women in the second trimester is 10.5 to 14 g/dL.
Choice B: A multiple gestation pregnancy may cause a higher hemoglobin level due to increased erythropoietin production by the placenta. The normal hemoglobin range for pregnant women with twins in the second trimester is 12 to 16 g/dL.
Choice C: Greater-than-expected weight gain is not related to hemoglobin level. Weight gain during pregnancy depends on various factors such as pre-pregnancy weight, nutrition, activity level, and fetal growth.
Choice D: Iron-deficiency anemia is a condition where the hemoglobin level is below the normal range due to inadequate iron intake or absorption, blood loss, or increased iron demand. The signs and symptoms of iron-deficiency anemia include fatigue, pallor, weakness, shortness of breath, and pica.
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because it is too early. Naegele's rule is a formula that estimates the date of birth by adding one year, subtracting three months, and adding seven days to the date of the last menstrual period. Applying this rule to April 11 gives February 18, not February 24.
Choice B Reason: This is incorrect because it is too early. Naegele's rule gives February 18, not January 18.
Choice C Reason: This is incorrect because it is too early. Naegele's rule gives February 18, not January 25.
Choice D Reason: This is correct because it follows Naegele's rule. Adding one year, subtracting three months, and adding seven days to April 11 gives February 18.