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 D
Explanation
Choice A: 28 weeks' gestation is too early to screen for group B streptococcus infection. Group B streptococcus (GBS) is a type of bacteria that can cause serious infections in newborns if transmitted from the mother during labor and delivery. The optimal time to screen for GBS is between 35 and 37 weeks' gestation.
Choice B: 32 weeks' gestation is also too early to screen for GBS infection. Screening at this time may not reflect the true colonization status of the mother at the time of delivery, as GBS can be transient or intermittent.
Choice C: 16 weeks' gestation is much too early to screen for GBS infection. Screening at this time has no clinical value, as GBS colonization can change throughout pregnancy.
Choice D: 36 weeks' gestation is the appropriate time to screen for GBS infection. Screening at this time can identify mothers who are colonized with GBS and who need intrapartum antibiotic prophylaxis to prevent neonatal sepsis, pneumonia, and meningitis.
Correct Answer is ["A","B","C","E"]
Explanation
Choice A Reason: Nausea is a common presumptive sign of pregnancy, especially in the first trimester. It is caused by hormonal changes and may be accompanied by vomiting.
Choice B Reason: Abdominal enlargement is another presumptive sign of pregnancy, as the uterus grows to accommodate the developing fetus. It may be noticeable as early as 12 weeks of gestation.
Choice C Reason: A positive pregnancy test is a presumptive sign of pregnancy, as it detects the presence of human chorionic gonadotropin (hCG), a hormone produced by the placenta. However, it is not a definitive sign, as it may be affected by other factors such as medications, tumors, or false positives.
Choice D Reason: Braxton Hicks contractions are not a presumptive sign of pregnancy, but a probable sign. They are irregular and painless contractions of the uterus that occur throughout pregnancy, but become more frequent and noticeable in the third trimester. They are also known as false labor contractions.
Choice E Reason: Amenorrhea, or the absence of menstrual periods, is a presumptive sign of pregnancy, as it indicates that ovulation has ceased. However, it is not a definitive sign, as it may be caused by other factors such as stress, illness, or hormonal imbalances.