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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because administering Rho(D) immune globulin 24 hours before delivery is too early and may not provide adequate protection for the fetus. Administering it 24 hours after delivery is too late and may not prevent the mother from developing antibodies against the fetal Rh-positive blood cells.
Choice B Reason: This is incorrect because administering Rho(D) immune globulin in the first trimester is unnecessary and may not be effective, as the risk of Rh isoimmunization is very low before 28 weeks of gestation. Administering it within 2 hours of delivery is appropriate, but not sufficient, as it should be repeated within 72 hours after delivery.
Choice C Reason: This is correct because administering Rho(D) immune globulin at 28 weeks gestation and again within 72 hours after delivery is the recommended schedule for preventing Rh isoimmunization in Rh-negative pregnant women who have Rh-positive partners. This regimen can prevent up to 99% of cases of Rh isoimmunization by blocking the maternal immune response to the fetal Rh-positive blood cells.
Choice D Reason: This is incorrect because administering Rho(D) immune globulin at 32 weeks gestation is too late and may not prevent Rh isoimmunization if there has been any fetal-maternal hemorrhage before that time. Administering it immediately before discharge is also too late and may not prevent the mother from developing antibodies against the fetal Rh-positive blood cells.
Correct Answer is B
Explanation
Choice A Reason: This is incorrect because difficulty in arousing is a sign of magnesium toxicity, which is a serious complication of magnesium sulfate therapy. Magnesium toxicity can cause central nervous system depression, muscle weakness, and cardiac arrest. The nurse should monitor the client's level of consciousness and stop the infusion if the client becomes lethargic or unresponsive.
Choice B Reason: This is correct because deep tendon reflexes 2+ indicate a normal and expected response to magnesium sulfate therapy. Magnesium sulfate is a muscle relaxant that can reduce the risk of seizures in gestational hypertension. The nurse should assess the client's deep tendon reflexes regularly and maintain them at 2+ or slightly diminished.
Choice C Reason: This is incorrect because urinary output of 30 mL per hour is below the normal range of 40 to 80 mL per hour and may indicate renal impairment or dehydration. Magnesium sulfate can cause renal toxicity or fluid retention, which can affect the urinary output. The nurse should monitor the client's urinary output and fluid balance and report any abnormalities to the doctor.
Choice D Reason: This is incorrect because respiratory rate of 10 breaths/minute is below the normal range of 12 to 20 breaths/minute and may indicate respiratory depression. Magnesium sulfate can cause respiratory depression or failure, which can be life-threatening. The nurse should monitor the client's respiratory rate and oxygen saturation and administer oxygen or antidote if needed.