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 ["B","C","D","E"]

Explanation

Choice A Reason: This is incorrect because ultrasound visualization of the fetus is a positive sign of pregnancy, not a probable sign. A positive sign of pregnancy is a direct and definitive evidence of the presence of a fetus, such as fetal movement felt by the examiner or fetal heart sounds heard by a Doppler device.

Choice B Reason: This is correct because softening of the cervix, also known as Goodell's sign, is a probable sign of pregnancy. A probable sign of pregnancy is a strong indication of pregnancy based on physical changes in the reproductive organs, such as enlargement of the uterus or changes in the shape and consistency of the cervix.

Choice C Reason: This is correct because a positive pregnancy test, which detects human chorionic gonadotropin (hCG) in urine or blood, is a probable sign of pregnancy. However, it is not a conclusive sign, as hCG can also be produced by other conditions such as ectopic pregnancy, molar pregnancy, or trophoblastic tumors.

Choice D Reason: This is correct because absence of menstruation, also known as amenorrhea, is a probable sign of pregnancy. It occurs when ovulation and menstruation cease due to hormonal changes during pregnancy. However, it is not a definitive sign, as amenorrhea can also be caused by other factors such as stress, illness, or hormonal imbalances.

Choice E Reason: This is correct because ballottement, which is a rebounding of the fetus against the examiner's fingers during a pelvic examination, is a probable sign of pregnancy. It can be felt around 16 to 20 weeks of gestation.

Choice F Reason: This is incorrect because auscultation of a fetal heart beat, which can be heard by a fetoscope around 18 to 20 weeks of gestation or by a Doppler device around 10 to 12 weeks of gestation, is a positive sign of pregnancy, not a probable sign.

A. Chadwick's sign B. Goodell's sign C. Hegar's sign D. Homan's sign

Correct Answer is A

Explanation

Choice A Reason: This is correct because Chadwick's sign is a bluish or purplish discoloration of the cervix, vagina, and vulva caused by increased blood flow to the pelvic area during pregnancy. It is one of the earliest signs of pregnancy and can be observed as early as six to eight weeks of gestation.

Choice B Reason: This is incorrect because Goodell's sign is a softening of the cervix due to increased vascularity and edema during pregnancy. It is another early sign of pregnancy and can be detected by palpation around six to eight weeks of gestation.

Choice C Reason: This is incorrect because Hegar's sign is a softening of the lower uterine segment or isthmus during pregnancy. It is also an early sign of pregnancy and can be felt by bimanual examination around six to twelve weeks of gestation.

Choice D Reason: This is incorrect because Homan's sign is a pain in the calf or popliteal region when the foot is dorsiflexed. It is a sign of deep vein thrombosis, which is a potential complication of pregnancy, but not a normal finding.

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 woman comes to the prenatal clinic suspecting that she is pregnant, and assessment reveals probable signs of pregnancy. Which findings would the nurse most likely assess? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

On the first prenatal visit, examination of the woman's internal genitalia reveals a bluish coloration of the cervix and vaginal mucosa. The nurse documents this finding as:

Correct Answer is A

Explanation

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