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 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.
Correct Answer is A
Explanation
Choice A reason: Hemorrhage is the most life-threatening complication of a ruptured ectopic pregnancy, as it can lead to hypovolemic shock and death. The nurse should monitor the client's vital signs, blood loss, and level of consciousness, and administer fluids and blood products as ordered.
Choice B reason: Edema is not a common sign of a ruptured ectopic pregnancy, and it is not a priority over hemorrhage. Edema may be caused by other conditions, such as heart failure, kidney disease, or venous insufficiency.
Choice C reason: Infection is a possible complication of a ruptured ectopic pregnancy, but it is not as urgent as hemorrhage. Infection may manifest as fever, chills, malaise, or foul-smelling vaginal discharge. The nurse should administer antibiotics as ordered and monitor the client's temperature and white blood cell count.
Choice D reason: Jaundice is not a typical symptom of a ruptured ectopic pregnancy, and it is not a priority over hemorrhage. Jaundice may indicate liver dysfunction or hemolytic anemia, which are unrelated to ectopic pregnancy. The nurse should assess the client's skin and sclera color, and check the liver enzymes and bilirubin levels.
