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 A
Explanation
Choice A Reason: This is correct because recurrent pelvic infections, such as pelvic inflammatory disease (PID), can cause scarring and inflammation of the fallopian tubes, which can impair the normal movement of the fertilized egg to the uterus. This can increase the risk of ectopic pregnancy, which is a life-threatening condition where the fertilized egg implants outside the uterine cavity, usually in the fallopian tube.
Choice B Reason: This is incorrect because ovarian cysts are fluid-filled sacs that develop in or on the ovaries. They are usually benign and do not affect fertility or pregnancy. However, some types of ovarian cysts, such as endometriomas or dermoid cysts, may require surgery to remove them, which can cause damage to the ovaries or fallopian tubes and increase the risk of ectopic pregnancy.
Choice C Reason: This is incorrect because use of oral contraceptives for 8 years is not a risk factor for ectopic pregnancy. In fact, oral contraceptives can reduce the risk of ectopic pregnancy by preventing ovulation and fertilization. However, if a woman becomes pregnant while taking oral contraceptives, she should stop taking them and consult her doctor, as they may have adverse effects on the developing fetus.
Choice D Reason: This is incorrect because heavy, irregular periods are not a risk factor for ectopic pregnancy. They may indicate other conditions such as hormonal imbalance, uterine fibroids, polycystic ovary syndrome (PCOS), or endometriosis, which can affect fertility or pregnancy, but not necessarily cause ectopic pregnancy.
