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: Hemodilution of pregnancy is a normal physiological phenomenon that occurs when the plasma volume increases more than the red blood cell mass, resulting in a lower hemoglobin concentration. The normal hemoglobin range for pregnant women in the second trimester is 10.5 to 14 g/dL.
Choice B: A multiple gestation pregnancy may cause a higher hemoglobin level due to increased erythropoietin production by the placenta. The normal hemoglobin range for pregnant women with twins in the second trimester is 12 to 16 g/dL.
Choice C: Greater-than-expected weight gain is not related to hemoglobin level. Weight gain during pregnancy depends on various factors such as pre-pregnancy weight, nutrition, activity level, and fetal growth.
Choice D: Iron-deficiency anemia is a condition where the hemoglobin level is below the normal range due to inadequate iron intake or absorption, blood loss, or increased iron demand. The signs and symptoms of iron-deficiency anemia include fatigue, pallor, weakness, shortness of breath, and pica.
Correct Answer is C
Explanation
Choice A: A clear liquid diet is not appropriate for a client with hyperemesis gravidarum, which is a severe form of nausea and vomiting during pregnancy that can lead to dehydration, electrolyte imbalance, and weight loss. A clear liquid diet does not provide adequate calories, protein, vitamins, or minerals for the client and the fetus.
Choice B: Administration of diethylstilbestrol is not indicated for a client with hyperemesis gravidarum. Diethylstilbestrol is a synthetic estrogen that was used in the past to prevent miscarriage and premature birth, but it was found to cause serious adverse effects such as vaginal cancer, infertility, and birth defects in the offspring.
Choice C: Total parenteral nutrition is the correct choice because it provides a complete and balanced source of nutrients through a central venous catheter. It is used for clients who cannot tolerate oral or enteral feeding due to severe gastrointestinal disorders such as hyperemesis gravidarum. It helps to prevent malnutrition, dehydration, and ketosis in the client and the fetus.
Choice D: Nothing by mouth is not a suitable option for a client with hyperemesis gravidarum. It can worsen the condition by causing starvation, acidosis, and ketosis. It can also increase the risk of aspiration pneumonia if the client vomits.