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 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.
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because ferrous sulfate is an iron supplement that is used to treat or prevent iron-deficiency anemia. It has no effect on magnesium sulfate, which is a medication that lowers blood pressure and prevents seizures in severe preeclampsia.
Choice B Reason: This is incorrect because potassium chloride is an electrolyte supplement that is used to treat or prevent low levels of potassium in the blood. It has no effect on magnesium sulfate, which can cause hypermagnesemia, or high levels of magnesium in the blood.
Choice C Reason: This is incorrect because calcium carbonate is an antacid that is used to treat or prevent heartburn, indigestion, or calcium deficiency. It has no effect on magnesium sulfate, which can cause hypocalcemia, or low levels of calcium in the blood.
Choice D Reason: This is correct because calcium gluconate is an antidote that is used to treat magnesium toxicity, which can occur when magnesium sulfate is given in high doses or for prolonged periods. Calcium gluconate reverses the effects of magnesium sulfate on the neuromuscular and cardiovascular systems, such as muscle weakness, respiratory depression, cardiac arrhythmias, or cardiac arrest.
