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 the correct answer because it is an empathetic and supportive response that acknowledges the client's loss and grief. This is an empathetic and supportive response that acknowledges the client's loss and grief. The other choices are inappropriate because they are insensitive, dismissive, or inaccurate.
Choice B Reason: This is an inappropriate answer because it implies that the nurse does not understand or care about the client's emotional state. It also suggests that the client has no Reason to cry, which is invalidating and hurtful.
Choice C Reason: This is an inappropriate answer because it focuses on the physical pain rather than the emotional pain of the client. It also implies that the nurse wants to avoid dealing with the client's feelings and just give them a medication to make them stop crying.
Choice D Reason: This is an inappropriate answer because it is inaccurate and misleading. A spontaneous abortion, also known as a miscarriage, occurs when a pregnancy ends before 20 weeks of gestation. At this stage, the baby is already formed and has a heartbeat, organs, and limbs. Saying that a baby still wasn't formed in the womb is false and insensitive to the client's loss.
Correct Answer is ["415"]
Explanation
To calculate the amount of NG drainage, the nurse should subtract the amount of irrigation fluid from the amount of fluid in the NG canister. The irrigation fluid is not part of the drainage, but rather a way to keep the NG tube patent and prevent clogging.
The amount of irrigation fluid is 30 mL x 2 = 60 mL.
The amount of fluid in the NG canister is 475 mL.
Therefore, the amount of NG drainage is 475 mL - 60 mL = 415 mL.
The answer should be rounded to the nearest whole number and use a leading zero if it applies. Do not use a trailing zero.
Therefore, the final answer is 415 mL.